(314) 772-0292 [email protected]

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New Client Form

Thank you for giving our hospital the opportunity to care for your pet. So that we may be better able to meet your needs,
please complete the following prior to your first appointment.

If you’d prefer to download the form, you may email the completed form to [email protected] or bring it with you to your first appointment.

Download New Client Form Download Financial Payment Policy

Owner's Name *

First

Last

Spouse/Co-Owner's Name

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Pet's Name *

Species *

Dog
Cat
Other

If Other, please specify. *

Pet Breed

Pet Color

Pet Birthday/Age

Sex

Male
Neutered Male
Female
Spayed Female

Does your pet have any allergies, special medications, or health problems we should know about?

Yes
No

If yes, what are they?

Did you adopt this pet from a rescue group?

Yes
No

If yes, what rescue group?

What was your pet's rescue name?

Dates Vaccinated

Add another pet?

Yes
No

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify. *

Pet Breed

Pet Color

Pet Birthday/Age

Sex

Male
Neutered Male
Female
Spayed Female

Does your pet have any allergies, special medications, or health problems we should know about?

Yes
No

If yes, what are they?

Did you adopt this pet from a rescue group?

Yes
No

If yes, what rescue group?

What was your pet's rescue name?

Dates Vaccinated

How did you hear of our hospital?

If you were referred by a friend, whom may we thank?

If other, please explain.

Has your pet been to a veterinarian before? *

Yes
No

Date of Last Visit

Please indicate your choice of payment method. *

Cash
Credit Card
Care Credit

We do NOT carry open accounts and hope the above methods are convenient for you.

I have received and read the Chippewa Animal Hospital Financial & Payment Policy. *

I have read and understand.

I agree to pay any costs and charges necessary for the collection of any amount not paid when due. To prevent the spread of infectious diseases and parasites, hospitalized or boarded animals must be current on all vaccines and be free of internal and external parasites. I authorize CHIPPEWA ANIMAL HOSPITAL to provide vaccines and parasite control when needed *

I have read and understand.

I verify that all the information provided is accurate. *

I have read and understand.

Owner's Signature *

Thank you for bringing your pet to our hospital. We hope you are pleased with our services and facilities and would appreciate your letting us know how we might improve them.

Message

We strive to offer excellence in veterinary care to South St. Louis and surrounding areas!

Location

4210 Itaska St., Suite B
St. Louis, MO 63116

Hours

Monday-Wednesday: 7:30am – 7:00pm
Thursday- Friday: 7:30am – 6:00pm
Saturday: 8:00am –2:00pm
Sunday: Closed

Appointments start at 9:00am

Financing Available

Contact Info

Phone: (314) 772-0292
Email: [email protected]

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