New Client

Vermilion Hillcrest Animal Hospital
2722 North Vermilion Street, Danville, IL 61832
Kate Brucker DVM Jill Bair DVM

Make an appointment - (217) 443-0333

                                                 Refer a client to us and get $25
                                                                      Click here.

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client

Name & Email (required)
First Name (required)	Last Name (required)

Address (required)
Street Address (required)


City (required)	State/Province (required)	Zip/Postal Code (required)
,

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone
Phone Type	Phone Number

E-Mail Address (required) :

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current?

Do you have pets medical records?

Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Would you like us to call you for your appointment

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Vermilion Hillcrest Animal Hospital and that charges are due and payable at the time of service.

I have read this statement and -
I Agree
I Disagree

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