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phone: 847-564-1500
fax: 847-715-9934

300 Skokie Blvd, Suite A
Northbrook, IL 60062

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New Client Registration Form

We Treat Your Pet Like Family

We are happy that you have chosen North Shore Family Pet to care for your pets. Please call our office or use our request appointment email to schedule an appointment for your pet.

In order to serve you better, prior to your appointment, please download our new client new patient registration form fill it out and bring it with you to your scheduled appointment.

New Client Registration Form - PDF

Online Registration Form

[*] Required fields, please fill out before submitting.

Owner Information

Owner First Name [*]

Owner Last Name [*]

Co-Owner First Name

Co-Owner Last Name

Address [*]

City, State & Zip [*]

Home Phone [*]

Work Phone

Cell Phone

Email [*]

Which number is preferred for reminders/callbacks?

For vaccination/appointment reminders, would you prefer and e-mail or postcard?

How did you hear about our practice? [*]

Do you have pet insurance? [*]

Who may we thank for referring you to our practice?

Pet Information

Patient Name [*]

Dog, Cat or Other [*]

Birth Date [*]

Male/Female [*]

Spayed or Neutered [*]

Breed [*]

Color [*]

Is your pet microchipped? [*]

When/Where did you obtain your pet? [*]

Patient History

Referring Veterinarian [*]

Primary Veterinarian [*]

Reason for visit [*]

Please list any medications you are giving: [*]

Please list other known medical conditions: [*]

Please list any allergies/vaccine reactions: [*]

Are there other pets in your household? Indicate how many and pet type: [*]

I assume responsibility for all charges incurred in the care of this animal. I further understand that these charges must be paid at the time of release. In admitting my pet(s) for examination, diagnostics, treatment, or surgery, I authorize the veterinarians of North Shore Family Pet Hospital, and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary. A 50% deposit may be required for hospitalization and/or surgical treatment. We will gladly prepare an estimate of fees at your request.

  • Registration Form
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We Treat Your Pet Like Family!

AAHA Accredited

AAHA Accredited

Cat Friendly Practice

Cat Friendly Practice

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