Owner's Information

All fields marked with * are required and must be filled.

Owner Name (Over 18 years)*

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Home Phone

Cell Phone

Email*

Owner's Employer

Employer's Phone Number

Co-Owner Name

First

Last

Co-Owner Phone Number

Preferred Method of Contact

Email
Text
Phone

Pet Information

Pet's Name

Breed

Color

Birth Date or Age

Gender

Male
Female

Neutered/Spayed

Neutered
Spayed
Intact

Add Another Pet?

Yes
No

Pet Information

Pet's Name

Breed

Color

Birth Date or Age

Gender

Male
Female

Neutered/Spayed

Neutered
Spayed
Intact

Capitol Illini – Chatham Location

How did you hear about our practice?

Internet
Hospital sign/location
Friend/Family Member/Co-Worker
Springfield Scene Magazine
Illinois Times
Phone Book
Referred by Veterinary Clinic:
Shelter Referral
Insurance Recommendation:

Friend/Family/Co-Worker Name

Name of Veterinary Clinic

Name of Shelter

Name of Pet Insurance

Capitol Illini would like permission to use your pet(s) photograph(s) either on the Website, Newsletter, Facebook, YouTube, and/or Other. Your pet’s information may be used, but we will not give any personal information of the owner such as name or address. Permission granted will only be used by Capitol Illini Veterinary Services, LTD. I give permission for Capitol Illini to use my pet(s) photograph(s).

Payment is Expected in Full at the Time of Service: A finance charge of 1.5% applied to all accounts unpaid after 30 days. A billing charge of $2.00 is added monthly. An Additional 35% of unpaid balance will be applied to any account that is being referred to a collection agency.

New Client Form – Springfield

Owner's Information

Pet Information

Pet Information

Capitol Illini – Chatham Location

Get in touch

(217) 483-6830

(217) 546‑1541

Business Hours

(217) 483-6830

(217) 546‑1541