New Client Form

Thank you for choosing Meadows Veterinary Clinic! We are looking forward to meeting you and your pet!
Please complete the following form to help us make your first visit more efficient. Once you submit the completed form, we will contact you within 1 to 2 business days for scheduling. If you have a pet emergency or your pet is currently ill, please contact our office at 309-694-0505 for faster scheduling!

What kind of appointment do we need to schedule for your pet? (for example, would you like to schedule for vaccines? an illness? surgery?) *

Please choose one: *

I need to schedule an appointment for my pet. Please give me a call after receiving my information. I have already scheduled my appointment, but I wanted to provide some additional information.

Personal Information

What is the best time and place to reach you? *

Please provide the Name and Relationship of any other persons that you want to allow to authorize care for your pet(s). *

Pet Information

This pet is a: *

Cat Dog

This pet is a: *

Spayed Female Intact Female (not spayed) Neutered Male Intact Male (not neutered)

Has your pet been seen previously by another veterinarian? If so, please provide the name of the previous clinic or doctor. *

Please select an option below: *

. I will bring my pet's medical records with me to my appointment . Please call my previous clinic and have the records transfered for me

Does your pet have any fears or dislikes? *

Does your pet have any food sensitivities or require a prescription diet? *

Has your pet experienced any adverse reactions to medications or vaccines in the past? *

Does your pet currently take any medication? *

Other Details

Preferred Method of Payment - Please check all that apply *

Cash Check Debit Card Visa, Mastercard, or Discover

We kindly ask that payment is made at time of service. Treatment plans with associated costs are available upon request. No charging is allowed, but if you need financial assistance, ask a staff member about our "90 Days Same As Cash" program through Personal Finance (pre-approval is needed to use this payment option). *

. I understand my payment options.

I authorize Meadows Veterinary Clinic to take photos of my pet and use these photos for any lawful purpose including, for example: illustration, advertising, or Web content. *

Yes No

I authorize Meadows Veterinary Clinic to release medical records for my pet(s) upon request (for example, if requested by grooming facility, kennel, daycare, emergency clinic, etc). *

Yes No

How did you become aware of our clinic? *

Drove by Yellow Pages or other advertisement Website or Facebook page Recommendation from a current client

If you were given a personal recommendation for our clinic whom may we thank? *