Client Registration Form

PET OWNER INFORMATION

Name*

Email*

Home Phone*

Cell Phone*

Mailing Address*

Employer*

Work Phone

PET INFORMATION

Pet Name*

Age*

Species*

Breed*

Coat Color*

Sex*

Male Intact
Male Neutered
Female Intact
Female Spayed

Up to date on vaccines?*

Yes
No

Current Medications*

Diet & Supplements*

Allergy History*

Has your pet traveled outside of LI and where?*

Reason for Today's Visit*

Primary Veterinarian Name & Practice Name*

Do you have pet insurance?*

Yes
No

How did you learn about us?*

My Veterinarian
Friend/Relative
East End Website
Veterinarians.com Website
Internet Search
Radio
Previous Visit
Other

If other, please specify.*

Please type your name to confirm that East End Veterinary Center has permission to use a photograph.*

CLIENT INFORMATION

Our Emergency exam fee is $180.00.

You will be advised of estimated costs of anticipated treatment/procedures after initial examination.

A deposit is required with the authorization of each estimate in the amount of the low-end or half the high-end (whichever is greater).

If collection and/or legal actions become necessary, you are fully responsible for all incurred fees. We aim to provide our patients with superb care and service. Please excuse any delays, we will give your pet the same careful attention, at the earliest opportunity.

Client Signature*

I hereby acknowledge the above and consent to the examination and consultation by the attending Clinician at East End Veterinary. I further understand that I am responsible for all fees, including exam, diagnostic, treatment, and/or surgical procedures, and am fully aware that this responsibility remains in the event my pet fails to recover.

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631-369-4513

CRITICAL CARE AUTHORIZATION FORM

PET OWNER INFORMATION

PET INFORMATION

CLIENT INFORMATION

CRITICAL CARE AUTHORIZATION FORM