312-929-2934 [email protected]

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New Client Form

Save time during your next appointment! Complete your required forms online from any device at any time before your visit.

New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Please have this form completed and submitted prior to your pet’s first appointment

Owner Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Primary contact number *

Secondary contact number

What is your preferred method of contact for general communication? *

Email
Cell Phone
Home Phone
Work Phone

Please list any person who is authorized to make medical or financial decisions regarding this patient. *

How did you hear about us? *

Veterinary Referral
Referred by a Friend
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Other

Authorization and Payment Policy

I hereby authorize the veterinarian to examine, prescribe or treat the above patient. I assume full responsibility for all charges incurred in the care of this animal. I also understand that these charges are to be paid in full at the time of release. Payments are expected when services are rendered. WE DO NOT BILL. In order to provide the best care, we accept all major credit cards (MasterCard, Visa, Amex, & Discover), Care Credit, and cash. Should collection and/or attorney’s fees become applicable I will be held responsible for those and all other costs of collection. By signing below, I hereby state that I am the owner or authorized agent of the above patient. We are teachers in the field of veterinary dermatology. Medical files, case information and/or photos may be used in teaching, continuing education, website, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; client confidentiality (Names and Personal Information) will be maintained. I understand that no guarantee can be made as to the result obtained from medical treatment. I have read the above terms and conditions and agree to adhere to this agreement. *

I agree

Cancellation and Late Arrival Policies

Please note our cancellation and late arrival policies: A 15-minute grace period is granted for each appointment time. Arriving past this grace period may forfeit the appointment time, and your appointment may be canceled. Should your initial consult appointment be canceled less than 24 hours prior to your pet’s exam (Monday appointments must be canceled by 12:00 pm on Friday before), you will forfeit your prepaid consultation fee. For future recheck late cancellations or no-shows, you will be charged a cancellation fee. After booking your initial consult, your credit card will be kept on file. *

I understand

Online Pharmacy Policy

Please note our online pharmacy policy: We do not deal directly with online pharmacies. We have had problems with patient monitoring as well as incorrect medication instructions in the past. We will provide a written prescription upon request, provided we have recently examined your pet and the particular medication or product is appropriate. Written prescriptions can be picked up during your appointment time or during normal business hours. *

I understand

Client Communication Policy

Please note our client communication policy: For all consultations, the pet’s owner and financial decision-maker must be available to speak with the doctor either in person or over the phone during the appointment. If the primary decision-maker is not available to speak with the doctor during the appointment time, the doctor will formulate a plan with their best recommendations based on the information provided. In an effort to serve all our patients, if additional time is needed to reformulate the plan because the primary decision maker was not available during the appointment, additional exam time must be scheduled. *

I understand

Cytology

Please note our cytology policy: Be prepared for additional cytology testing during the examination. In our clinic, 95% of cases require cytology during the exam. Cytology is a sample of the skin or ears examined on a glass slide to look for types of skin cells, types of infections, and types of inflammatory cells. Cytology is a tool that directs the veterinary dermatologist to the best plan of action. An estimate will be provided after the exam and cytology for any additional items (cultures, lab work, biopsy, medications, etc.). *

I understand

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We’re excited to meet you

We proudly serve the pets of Chicago and the surrounding areas. We look forward to seeing you and your pet! You may request an appointment by giving us a call at 312-929-2934.

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Get in Touch

Phone: 312-929-2934
Email: [email protected]

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Where to Find Us

1030 N. Larrabee Street
Chicago, IL 60610

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Our Hours

Monday 8:00am-5:00pm

Tuesday 8:00am-5:00pm

Wednesday 8:00am-5:00pm

Thursday 8:00am-5:00pm

Friday 8:00am-12:00pm

Have a question? Complete our online form, and we will be in touch with you shortly.

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