Please note: We will be closed on Tuesday, December 24th, Wednesday, December 25th, and Thursday, December 26th, in observance of Christmas!

New Client & Pet Information

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Welcome to Perryville Pet Hospital!

Please take 3-5 minutes to complete the questions below about yourself and your pet(s). You can either fill out the form online and submit or download, print and email to [email protected]. This will allow us to be more efficient at the time of your appointment.

download & print form

How did you find us? *

Referred by family/friend
Internet
Facebook
Nextdoor App
Perryville Pet Website
Event
Other

Who referred you? We'd love to thank them!

Which Event?

If Other, please explain:

Client Information

Name *

First

Last

Your DOB *

Email *

*PetDesk is our new app to send appointment reminders, pet updates and lab results for your pet via text or email. Email is required to upload your pets’ data into the app.
*However, you can OPT-OUT of emails after you register.

Cell Phone *

Home Phone

Work Phone

Secondary Pet Parent Name

First

Last

Cell Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please select one: *

I give Perryville Pet Hospital permission to include photos of, or references to my pet(s), on our website or any social media (your personal information will never be shared).
No I do not give permission.

Pet Information

Pet Name *

Species *

Breed *

Color/Markings *

Birthday or Age *

Sex *

Male
Female

Spayed/Neutered? *

Is your pet up to date on their rabies vaccine? *

Yes
No
Don't Know

*Oct 2019, Illinois mandated that all dogs/cats over 4mo of age be vaccinated for Rabies. If vet determines pets health is compromised, the vaccine can be administered at a later appointment*

Rabies vaccine is/was due (month/year)

Current Meds/supplements?

Current heartworm preventative?

Heartgard
ProHeart
Other

If Other, please specify

Do you give:

Seasonal
Monthly
Year Round
Other

If Other, please specify.

Current flea/tick preventative?

Nexgard
Frontline
Other

If Other, please specify.

Do you give:

Seasonal
Monthly
Year Round
Other

If Other, please specify.

Your pet's current diet:

How much do you feed your pet daily?

List treats or non-dog food given to your pet:

Does your pet have a history of fear or anxiety in the car?

Does your pet have a history of fear or anxiety at the vet?

Has your pet ever been given an anti-anxiety before any prior vet appointments?

If so, what?

Would you like to add information for a second pet? *

Pet Name *

Species *

Breed *

Color/Markings *

Birthday or Age *

Sex *

Male
Female

Spayed/Neutered? *

Is your pet up to date on their rabies vaccine? *

Yes
No
Don't Know

*Oct 2019, Illinois mandated that all dogs/cats over 4mo of age be vaccinated for Rabies. If vet determines pets health is compromised, the vaccine can be administered at a later appointment*

Rabies vaccine is/was due (month/year)

Current Meds/supplements?

Current heartworm preventative?

Heartgard
ProHeart
Other

If Other, please specify.

Do you give:

Seasonal
Monthly
Year Round
Other

If Other, please specify.

Current flea/tick preventative?

Nexgard
Frontline
Other

If Other, please specify.

Do you give:

Seasonal
Monthly
Year Round
Other

If Other, please specify.

Your pet's current diet:

How much do you feed your pet daily?

List treats or non-dog food given to your pet:

Does your pet have a history of fear or anxiety in the car?

Does your pet have a history of fear or anxiety at the vet?

Has your pet ever been given an anti-anxiety before any prior vet appointments?

If so, what?

Would you like to add information for a third pet? *

Pet Name *

Species *

Breed *

Color/Markings *

Birthday or Age *

Sex *

Male
Female

Spayed/Neutered? *

Is your pet up to date on their rabies vaccine? *

Yes
No
Don't Know

*Oct 2019, Illinois mandated that all dogs/cats over 4mo of age be vaccinated for Rabies. If vet determines pets health is compromised, the vaccine can be administered at a later appointment*

Rabies vaccine is/was due (month/year)

Current Meds/supplements?

Current heartworm preventative?

Heartgard
ProHeart
Other

If Other, please specify.

Do you give:

Seasonal
Monthly
Year Round
Other

If Other, please specify.

Current flea/tick preventative?

Nexgard
Frontline
Other

If Other, please specify.

Do you give:

Seasonal
Monthly
Year Round
Other

If Other, please specify.

Your pet's current diet:

How much do you feed your pet daily?

List treats or non-dog food given to your pet:

Does your pet have a history of fear or anxiety in the car?

Does your pet have a history of fear or anxiety at the vet?

Has your pet ever been given an anti-anxiety before any prior vet appointments?

If so, what?

Would you like to add information for a fourth pet? *

Pet Name *

Species *

Breed *

Color/Markings *

Birthday or Age *

Sex *

Male
Female

Spayed/Neutered? *

Is your pet up to date on their rabies vaccine? *

Yes
No
Don't Know

*Oct 2019, Illinois mandated that all dogs/cats over 4mo of age be vaccinated for Rabies. If vet determines pets health is compromised, the vaccine can be administered at a later appointment*

Rabies vaccine is/was due (month/year)

Current Meds/supplements?

Current heartworm preventative?

Heartgard
ProHeart
Other

If Other, please specify.

Do you give:

Seasonal
Monthly
Year Round
Other

If Other, please specify.

Current flea/tick preventative?

Nexgard
Frontline
Other

If Other, please specify.

Do you give:

Seasonal
Monthly
Year Round
Other

If Other, please specify.

Your pet's current diet:

How much do you feed your pet daily?

List treats or non-dog food given to your pet:

Does your pet have a history of fear or anxiety in the car?

Does your pet have a history of fear or anxiety at the vet?

Has your pet ever been given an anti-anxiety before any prior vet appointments?

If so, what?

Where do you purchase your preventatives?

Perryville Pet Hospital
Online Pharmacy
Local Pharmacy
Other

If Other, please specify.

Have you scheduled an appointment? *

Please specify which pet this appointment is for.

Reason for visit:

Has your pet been to a veterinarian before? *

Prior Vet Clinic & City

Upload prior records here

Click or drag files to this area to upload. You can upload up to 5 files.

I understand that payment is required at the time services are rendered. I hereby authorize the staff at Perryville Pet Hospital to render any treatment which is deemed necessary to the health of my pet(s) while in custody of the hospital. I understand that in the event of any unusual or emergency circumstances, the staff will make every attempt to contact me or my designated representatives before, if time permits, proceeding the treatment. I understand that I will be financially responsible for all emergency procedures including the Estimate of Charges provided to me in person or over the telephone. I understand that a non-refundable deposit of $50.00 is required for a NEW pet exam to secure the appointment. I understand that any unpaid balance over 60 days may be sent to a third party collections agency, with all fees for collections services added to the balance for services. Download this form, fill it out and email it to: [email protected] or print it and bring it with you to your appointment. *

I have read and understand

Phone

Ready to Visit?

Too book your next appointment
please call our office at 815-229-1234.

Appointment

Questions?

Contact Us

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Location

1917 Daimler Road
Rockford, IL 61112

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Contact Information

Phone: 815-229-1234
Email: [email protected]

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Hours

Mon-Fri: 8:00 am – 6:00 pm
Occasional Saturdays: 8 am – 12 pm
Sun: Closed

After regular business hours and on holidays, Guardian Vets is here!

Emergency Information

We are pleased to provide after hours emergency consultations from a licensed veterinary professional. These individuals will help to determine whether or not a trip to the Emergency Vet is necessary. To reach one of our on-call professionals:

Call our main number: (815) 229-1234.
When prompted, press 1.

Your call will automatically be connected to a licensed veterinary professional who will triage the emergency. No sitting on hold, no leaving a message with a service.

If the On-Call veterinary professional suggests you see a vet immediately, please click here to see the Emergency Hospitals we recommend.