East Rockaway Veterinary Hospital

351 Atlantic Avenue
East Rockaway, NY 11518

(516)887-3322

www.erockvet.com

New Patient Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooperation in letting us assist you.

New Patient

Name & Email (required)

First Name (required)	Last Name (required)

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

E-Mail Address :

Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :

Breed: (required)

Color: (required)

Sex: (required)

Male
Female

Neutered/Spayed (required)

Neutered
Spayed
Not Spayed or Neutered

Are Your Pet's Vaccines Current? (required)

Yes
No

Do You have Medical records From Your Previous Veterinary Practice? (required)
(Please make sure to bring copies of all previous vaccination, health history, and lab results. You can also fax documents to (516) 596-0310)

Yes
No

Name of Former Veterinary Practice (required)

May we request a transfer of records? (required)

Yes
No

Reasons or conditions that prompted your visit? (required)

List Any Current Medications (required)

List Any Current Or Previous Medical Conditions (required)

List Any Allergies (required)

Please list any additional pets here

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

Via Phone Text Message
Via Email

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

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 $95 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 $95 deposit is NON REFUNDABLE.

Type your last 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 typing in your last name (required)

(required)
Check this box to acknowledge that you have read and agree to the NON REFUNDABLE appointment cancellation policy. You cannot submit this form without checking this box

Verify the reCAPTCHA:

Call Us

(516) 887-3322

email us

Follow @eastrockawayvet

DAY OF WEEK	OPEN TIME	CLOSE TIME
Monday	9:00 AM	6:00 PM
Tuesday	9:00 AM	7:00 PM
Wednesday	9:00 AM	4:00 PM
Thursday	9:00 AM	7:00 PM
Friday	9:00 AM	4:00 PM
Saturday	9:00 AM	2:00 PM
Sunday

East Rockaway Veterinary Hospital

Where Pets Truly Are Members of The Family

East Rockaway Veterinary Hospital

New Patient