East Rockaway Veterinary Hospital

351 Atlantic Avenue
East Rockaway, NY 11518

(516)887-3322

www.erockvet.com

New Client 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 Client

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)

Sex: (required)

Male
Female

Neutered/Spayed (required)

Neutered
Spayed

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

List Any Current Or Previous Medical Conditions

List Any Allergies

Please list any additional pets here

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.

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Call Us

(516) 887-3322

email us

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