Hill-Dale Veterinary Hospital

536 Berkley Boulevard
Baraboo, WI 53913

(608)356-9433

hill-dale.com

New Client Check In

If you would like to make an appointment, please fill out the following form.

Thank you for your cooperation!

New Client

Name & Email (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
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State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female


Neutered/Spayed (required)
Neutered
Spayed


Do you have copies of your pet's medical records? (required)
Yes
No
Some


Medical records at another veterinary Practice?
Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No


Please call me to schedule an appointment.
Reasons or conditions that prompted your visit request?

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 Hill-Dale Veterinary Hospital, S.C. and that charges are due and payable at the time of service. Any balance that is carried will accrue a monthly finance charge of 1.5% (minimum of $3.00) or 18% per annum. Any balance that I leave unpaid will be forwarded to Hill-Dale Veterinary Hospital, S.C.'s collection agency, and will incur collection fees for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree



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