217-367-1187 contact@beaumontanimalclinic.com

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New Client Form

You can expedite your check-in by submitting this form prior to your first visit.

New Client Check In

You can expedite your check-in by submitting this form prior to your first visit.

New Client (BAC)

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Client's Birthday *

Daytime Phone

Layout

Cell Phone Number *

Home Phone Number

Work Phone Number

Evening Phone

Layout

Cell Phone Number *

Home Phone Number

Work Phone Number

E-Mail Address *

Pet's Name *

Age/Date of Birth *

Type of Pet

Canine
Feline
Avian
Exotic
Other

Breed *

Color *

Sex *

Male
Female

Neutered/Spayed *

Neutered
Spayed

Special requests or conditions?

Please list any additional pets here

How did you hear about us? *

Friend
Sign or Clinic
Internet
Yellow Book
Humane Society
Professional Referral

If referred by a friend, please tell us their name.

Referral Name

Name *

First

Last

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 Beaumont Small Animal Clinic PC and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. I agree to pay all reasonable costs incurred to collect this debt. This includes, unless prohibited by law, all reasonable attorney fees, filing fees, court costs, collection agency costs, service fees, and other related collection costs or contingencies. I understand that if any unpaid balance is turned over to a collection agency that a fee ranging from 30%-50% will be added to the total balance due. I hereby give you or any of your agents or assignees to whom you turnover any unpaid balance permission to obtain a report from a credit reporting agency and to take reasonable steps to verify my credit and or employment information. I give you or any of your agents or assignees to whom you turnover any unpaid balance to contact me regarding this transaction or any future transaction at any telephone numbers of which they are aware including cellular telephones by manually dialing, using an auto-dialer or pre-recorded message. *

I have read this statement and I agree
I have read this statement and I disagree

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Book An Appointment

We proudly serve the pets of Champaign, Urbana, Savoy, Tolono, IL, and the surrounding areas. We look forward to seeing you and your pet! Book an appointment by clicking the button below.

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Have a Question?

Please complete the form below, and a member of our team will get back to you as quickly as possible.

Name *

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Last

Email *

Phone

How can we help you? *

Website

Visit any of our conveniently located clinics.
Your pet’s records are accessible at all three locations!

Beaumont Animal Clinic

Contact Information

Phone: 217-367-1187
Email: contact@beaumontanimalclinic.com
Address: 1304 N Cunningham Ave.
Urbana, IL, 61802
Hours: Mon – Fri: 7:30 am – 6:00 pm
Sat: 7:30 am – 12:00 pm
Sun: Closed

Village Pet Doctor

Contact Information

Phone: 217-485-7387
Email: contact@villagepetdoctor.com
Address: 411 N Long St.
Tolono, IL, 61880
Hours: M-T-T-F: 7:30 am – 6:00 pm
Sat: 7:30 am – 12:00 pm
Wed & Sun: Closed

Country View Vet Clinic

Contact Information

Phone: 217-485-7387
Email: contact@countryviewvetclinic.com
Address: 2619 W Springfield Ave.
Champaign, IL, 61821
Hours: Mon – Fri: 7:30 am – 6:00 pm
Sat: 7:30 am – 12:00 pm
Sun: Closed

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