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730 Hibbard Rd., Wilmette IL 60091

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ABOUT
SERVICES
CLIENT CENTER
- Advanced Diagnostic Center
- Pet Health Links
SURGICAL & DIAGNOSTIC CENTER
HOURS
CAREERS
BLOG
CONTACT

New Client Form

Welcome New Clients!

Marked Fields Are Required (*)

CLIENT INFORMATION
Name*
Primary Contact Number*
Primary Contact Number is:*
- Home
- Work
- Cell
Spouse's Name
Spouse's Phone
Spouse's Contact Number is:
- Home
- Work
- Cell
Address*
Street Address Address Line 2 City State ZIP Code
Email (for Dr. communications, updates, information, and special offers)*
Emergency Contact Name*
Emergency Contact Phone*
How did you hear about us?*
- Google Search
- Internet Ad
- Facebook
- Website
- Hospital Sign
- Welcome Letter
- Friend/Family Member
- Other
If "Friend/Family" above, whom can we thank?
If "Other" above, please let us know how you heard of us.
PATIENT INFORMATION
Pet's Name*
Species*
- Dog
- Cat
- Other
What Species?*
Sex*
- Male
- Female
Spayed / Neutered?*
- Yes
- No
- I don’t know
Age*
Breed*
Color*
Would you like to add a second pet?
- Yes
- No
Additional Pet
Pet's Name*
Species*
- Dog
- Cat
- Other
What Species?*
Sex*
- Male
- Female
Spay / Neutered?*
- Yes
- No
Age*
Breed*
Color*
Please email us records from another animal hospital or provide authorization for us to request them.
Other Animal Hospital Name
Other Hospital Telephone
Upload available records (.jpg and .pdf only)
Drop files here or
Accepted file types: jpg, pdf, Max. file size: 50 MB.
Treatment Authorization
I authorize Christensen Animal Hospital, Dr. Jeffrey R. Moll and his staff to perform medical and/or surgical procedures required for the diagnosis and treatment of my pet. I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I understand that during the performance of the procedure(s) unforeseen conditions may be revealed that necessitate an extension of the scheduled procedure(s) or different procedure(s) than those originally anticipated and discussed. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment. I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed and my financial obligation remains regardless of the outcome. I understand that images of my pet may be used for educational, promotional or diagnostic purposes. I understand and acknowledge that I am responsible for all fees incurred during this visit. Unless other arrangements have been made, in advance, payment is expected at the time of discharge.*
- I authorize and agree
Photo Release: We often use patient pictures for our website, social media, and training programs. Your signature authorizes use of photos that may contain images of your pet. You also agree not to file any claim for revenue, or lawsuit for damages against Christensen Animal Hospital with respect to the release of photographs and information.*
- Yes
- No
If a situation calls for it, Christensen Animal Hospital may share your contact information with trusted partners.*
I approve
Financial Policies
ALL FEES ARE DUE AND PAYABLE UPON RELEASE OF YOUR PET. We will gladly prepare a written estimate if you so desire. A deposit may be required for hospitalized, medical, or surgical cases. We accept cash, checks, Visa, Mastercard, Discover, and CareCredit as forms of payment. Please note there is a $35.00 service charge on all checks that are returned for non-sufficient funds. Any unpaid balance will accrue a finance charge at a rate of 1.75% monthly, with a minimum finance charge of $5.00. I assume financial responsibility for all charges incurred to the patient. I have read and understand the financial policies. I further understand that if I do not pay the entire amount, I will be responsible for any and all fees incurred in collecting unpaid balances including but not limited to attorney fees, court costs, and collection agency fees, etc.*
- I understand and agree
Name*
First Last
Signature*
Date
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HOSPITAL AFFILIATIONS

Illinois State Veterinary Medical Association

Chicago Veterinary Medical Association

Association of Avian Veterinarians

HOSPITAL HOURS

MONDAY – FRIDAY: 8:00 am – 5:30 pm
SATURDAY: 8:00 am – 2:00 pm
SUNDAY: CLOSED

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Veterinarians in Wilmette, IL

Christensen Animal Hospital

730 Hibbard Road Wilmette, IL 60091

(847) 251-2600

Christensen Animal Hospital provides excellence in veterinary care to the pets of Wilmette IL, Winnetka, Glenview, Kenilworth, Northfield, and surrounding communities.

https://pawdr.com

Veterinary Website Design by Cheshire Partners

TWO EASY WAYS TO REACH US:

2 – TEXT US OR CALL US
(847) 251-2600 – (Texting may be the fastest way to communicate with us since phone lines may be jammed during peak hours)

3 – CONTACT FORM
Please use the CONTACT FORM and we will get back to you in a timely manner.

HOSPITAL HOURS

Monday - Friday: 8am - 5:30pm
Saturday: 8am - 2pm
Sunday: Closed