New Patient Form

Name: Northwest Animal Hospital
Address: 2024 S River Rd, Des Plaines, IL, 60018, United States
Telephone: 847-296-3112
Price range: $

Thank you for choosing Northwest Animal Hospital! Please fill out the form as completely and accurately as possible.

Get started

New Patient Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 847-296-3112 for a faster response.

Owner's Name *

First

Last

Email Address *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Work Phone

Mobile Phone

Can we text you?

Patient Information

Patient's Name *

Type of Animal *

(dog, cat, etc.)

Breed

Sex *

Male
Female

Weight of Patient

Is your pet neutered? *

Color *

Age / Birthday *

Previous Animal Hospital

Previous Animal Hospital’s phone number

Appointment Information

Have an appointment already? Let us know when we'll see you!

Appointment Date / Time

Date

Time

Notes

Additional Information

Please note additional information below. Please do not send any time-sensitive information; instead, contact Northwest Animal Hospital in person or by phone.

New Patient Form

New Patient Form

Patient Information

Appointment Information

Notes

We're Excited to Meet You

Contact Us

Address

Contact

Hours