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New Patient Form

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

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New Patient 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

Cell Phone *

Home Phone *

Email Address *

Pet's Name *

Age: Years, Months *

Type of Pet *

Breed *

Color *

Sex *

Neutered / Spayed

Are Your Pet's Vaccines Current?

Please make sure to bring copies of all previous vaccination, health history, and lab results. You can also send documents to erockvet@gmail.com

Do You have Medical records From Your Previous Veterinary Practice?

What was your previous Veterinary Hospital?

Do you provide permission to request Medical Records?

Reasons or conditions that prompted your visit? *

List Any Current Medications *

List Any Current Or Previous Medical Conditions *

List Any Allergies *

Please list any additional pets here

How would you like to receive reminders and communications from our office?

How did you hear about us? If a friend referred you, please give us their name

Or if you were referred by one of the following

PLEASE READ:

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal(s). I also understand that ALL PROFESSIONAL FEES ARE DUE AT TIME SERVICES ARE RENDERED.

APPOINTMENT POLICY:

New Clients are required to place a deposit of $101 for the first visit. You have 48 hours prior to the visit to cancel or reschedule this appointment without penalty. If the appointment is not kept or cancelled the $101 deposit is NON REFUNDABLE.

Sign your name in the box below to acknowledge that you have read and agree to the NON REFUNDABLE appointment cancellation policy. You cannot submit this form without a digital signature. *

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Online form

New Patient Form

New Patient Form

PLEASE READ:

APPOINTMENT POLICY:

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