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Medical Observation Form

Save time at your next appointment! Please complete your required Medical Observation Form online from any device at any time before your visit.

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Medical Observation Form

Please complete this form completely and accurately so that we can get to know you and your pet(s) before your visit. If this is an emergency or your pet requires immediate attention, please call us at 516-887-3322 for a faster response.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Contact Phone Number *

Emergency Phone Number *

Email Address *

Pet's Name *

Date of Check IN *

Date of Pick UP *

How many times a day does your pet eat? *

Please give us detailed feeding instructions *

Does your pet have any special dietary needs? *

Please list all medications that your pet is taking and dosing schedule *

Please list any belongings you are leaving with your pet *

AUTHORIZATION:

The undersigned hereby warrants that they are the owner or authorized agent for the pet listed in this record and does consent and authorize The East Rockaway Veterinary Hospital to care for and treat said pet. If an emergency situation arises, I authorize services, including use of anesthesia if necessary, to treat my pet until such time as I can be contacted. I understand that every reasonable effort will be made to contact me as soon as possible if an emergency or unanticipated situation arises with my pet. If I am unable to be reached, I authorize the veterinarians to proceed with treatment as deemed necessary for the well being of my pet. I understand that I will be responsible for all charges incurred at check out.

Please Note

All pets must be picked up by 1 p.m. or a 1/2 day boarding fee will be charged. *

I have read the authorization notice and agree

Client's Name *

First

Last

Digital Signature *

By signing, you are acknowledging that you have read the disclaimer.

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Online form

Medical Observation Form

Medical Observation Form

AUTHORIZATION:

Please Note

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