New Client Form

Name: The Village Veterinarian
Address: 306 North Main, Chatham, IL, 62629, United States
Telephone: 217-483-6000
Price range: $

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Thank you for choosing us!

Please fill out the form below. If you have any questions, give us a call at 217-483-6000. Please Note: All fields with * are required.

New Client Form

Primary Contact

(Must be 18 years of age or older)

Name *

First

Last

Email *

Primary Phone Number *

Date of birth *

Secondary Contact

Name

First

Last

Email

Secondary Phone Number

Address *

Address Line 1

Address Line 2

City

State

Zip Code

PROFESSIONAL FEES MUST BE PAID AT THE TIME OF SERVICE We accept Paypal, Venmo, credit/debit cards, Care Credit, cash, and checks I understand that full payment is due when services are rendered. I agree to pay any additional expense should a lawsuit or other outside source become necessary to collect my account, including reasonable attorney fees. I certify that I am of legal age. *

I have read and understand.

Owner/Agent Signature *

Clear Signature

Date *

Email

New Clients: Receive $25 off your first visit!

Please Note: We will be closing early at 12 PM on Tuesday, December 24th and will be fully closed on Wednesday, December 25th in observance of Christmas!

New Client Form

Thank you for choosing us!

New Client Form

Primary Contact

Secondary Contact

Are you ready for a visit to see us?

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Compassionate Veterinary Care in Chatham, IL

Compassionate
Veterinary
Care in Chatham, IL

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