East Rockaway Veterinary Hospital

351 Atlantic Avenue
East Rockaway, NY 11518

(516)887-3322

www.erockvet.com

All Patients Must Be Current On Vaccinations.

Dogs (Rabies, DHLPP, Bordetella, Influenza) Cats (Rabies, FVRCP)

Dogs must be current with Heartworm Preventative and testing.

All Pets Will Receive Capstar Flea Adulticide Upon Admission

Medical Observation

Name (required)

First Name (required)	Last Name (required)

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Contact Number (required)
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Emergency Contact Number (required)
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Date of Check IN (required)

Date of Pick UP* (required)

How many times a day does your pet eat? (required)

Does your pet have any special dietary needs? (required)

Please list all medications that your pet is taking and dosing schedule (required)

Please list any belongings you are leaving with your pet (required)

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- (required)

Agree
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