New Client/Patient Form

We will do our utmost to provide your pet(s) with the best possible care. Please feel free to contact our office at (219) 319-0679 regarding the health and well-being of your pet(s)

Pet Information

Pet 1

BreedBreed*

Pet NamePet Name*

AgeAge*

Pet's Date of BirthPet's Date of Birth (or approximate date)*

ColorColor*

+ Add Pet

For Referrals/Emergency clinic patients only:

Client NameClient Name

Doctor NameDoctor Name

Owner Information (No Minor Children)

Owner Name(s)

First NameFirst Name*

Last NameLast Name*

Spouse First NameSpouse First Name

Spouse Last NameSpouse Last Name

Owner Contact Information

Street AddressStreet Address

P.O. BoxP.O. Box

CityCity

ZipZip

Primary PhonePrimary Phone*

Secondary PhoneSecondary Phone

Email AddressEmail Address*

How Did You Learn of our Clinic?

Please Leave Blank: Please Leave Blank:

Payment Policy

Payment is due in full at the time of each visit.
We accept cash, check, VISA, MasterCard, Discover, American Express, debit cards, Care Credit and money orders.

Questions?

If you have any questions about the New Client/Patient Form give us a call at (219) 319-0679 and we’ll be happy to assist you.

I have read and agree to the Payment Policy.

Plan Ahead for Your Visit

Save time by filling out our New Client/Patient Form and get directions to our office.

New Client/
Patient Form Get Started

3D rendering of Crossroads Animal Hospital building

Our
Location Get Directions