New Patient Registration

Please schedule an appointment before filling out the New Patient Registration form below.

Owner's Name(Required)







Address















Sex


Neutered/Spayed:




Per Illinois law, does a court ordered ownership agreement apply to this animal?


I herby state that the information is true and correct to the best of my
knowledge. I further agree that if I am not the owner or responsible party that I may still be held responsible to provide payment for any services that I order or authorize.


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Video/Photo Release

I hereby grant Best Friends Animal Hospital irrevocable right and permission to use photographs and/or video recordings of my pet and other websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me.

I understand and agree that such photographs and/or video recordings of my pet may be placed on the Internet. I also understand and agree that I may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of my pet. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of the company.

I hereby release, acquit and forever discharge Best Friends Animal Hospital, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.

I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assigns and personal representatives.

Accept or Decline



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