New Client Form | NYC Veterinary Group (Midtown, LIC and Court Square)

Welcome, New Clients!

Thank you for giving us the opportunity to care for your pet. Please help us learn more about you and your pet’s needs by filling in the information below. When you are finished, click the submit button and the form will automatically be sent to our client service and medical team. Use one form per pet, please.

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"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Pet Owner Information:

What location would you like to visit?*

Do you already have an appointment scheduled with us? If so, when is the appointment scheduled for?

Primary Pet Owner*

First* Last*

Spouse / Co-Owner

First Last

Primary Phone*

Secondary Phone

Primary Email*

Secondary Email

Address:*

Street* City* State* Zip Code*

Check Us Out on Social Media

We are on Facebook, Twitter, Google+, Yelp, and Instagram By signing below you authorize the staff of NYC Vet Group to use photographs of this pet for promotional purposes including but not limited to brochures, website, and social media such as Facebook and Instagram.

First Last

Referral

How did you find out about our hospital?**

Personal Recommendation? Whom may we thank?

Pet Information

What kind of animal is your pet?

Dog

Cat

Pet's Name*

Breed*

Color*

Date of Birth*

What gender is your pet?*

Spayed/Neutered?

Is your pet Microchipped? What is the #? If you do not know ask us to scan your pet!*

Which Pet insurance does your Pet have?*

Heartworm/ Flea/ Tick Preventative*

Past Conditions / Allergies

Does your pet have any medical conditions or history that we should know about? Please use this field below to list any major medical problems that your pet may have had in the past, any chronic health issues, or anything else that you think will be helpful for us to know when diagnosing or treating your pet.

Is Your Pet On Any Medication

Use this field to tell us any medications that your pet is currently taking. List the medication name, the dose, and how frequently the medication is given.

Client Consent

To prevent the spread of infectious disease; all in-house, out-patient and boarders must be current on all vaccines and free of parasites. I understand this to be the strict policy of the hospital and authorize the doctors to provide my pet(s) with vaccinations and parasite control as needed. Any necessary treatments will be included on the invoice and due at the time of treatment.

We kindly request that ALL services are paid at the time they are provided. All outstanding balances will be sent to collections. Client acknowledges personal financial responsibility for services received. In the event of an emergency and I am not able to be reached, I authorize and agree to pay for any service NYC Vet Group determines necessary to provide the highest standard of care to my pet. I acknowledge that I am the owner of the patient listed above or that I am authorized by the owner to make medical decisions on its behalf. In cases where the rightful owner fails to make payments for any medical decisions made, I will assume the financial responsibility for the decisions I have made.

For your convenience we gladly accept cash, debit cards, Visa, MasterCard, and American Express. Sorry No Checks Accepted. DEPOSITS MAY BE REQUIRED FOR PETS BEING ADMITTED.

By signing below you acknowledge and agree to the above statements and also certify that you are at least 18 years of age.

Owner Signature*

First* Last*

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