New Client FormNew Client Form Owner’s First NameOwner's Last NameHome AddressCityStateZipPrimary Phone NumberSecondary Phone NumberDo you want to receive text message alerts and communication? YesNoEmail Address Are you active in the military, police, firefighter , clergy or retired? (must provide ID)How did you hear about us? Patient’s Information SpeciesDogCat Pet's Name Pet's Breed Pet's Color Pet's Birthday Pet's Sex Female IntactFemale SpayedMale IntactMale Neutered Has your pet been spayed and neutered?YesNo Has your pet had an adverse reaction to medications or previously given vaccines?YesNoWho may we contact for pet's previous veterinary records? (Please include name & phone # if applicable) [group group-28 clear_on_hide] If yes, which medication or vaccines and what happened?[/group] Does your pet have insurance?YesNo[group group-271 clear_on_hide] If yes, Policy Number and Name [/group]**Please note our software is only integrated with Trupanion and therefore only submit their claims ** Social Media Release I hereby authorize the use of photos and/or videos related to my pet’s experience at Rockaway Animal Hospital. I understand my pet may be used in publications, posts, videos or stories on our social media platforms. My consent is freely given as public service without expecting payment. I release this establishment and their respective employees from any and all liability which may arise from the use of videos and or photographic images.YesGuarantor Form As the owner/ co owner of my pet (s) account I understand and acknowledge that full payment is due at the time of service, pick up ,drop off or purchase of products for my pets accounts(initial) As the owner/ co owner of my pet (s) account I understand and acknowledge that Rockaway Animal Hospital doesn't offer in-house payment options, if I am in need of a payment solution I should use Icare, Care Credit or Scratchpay(initial) As the owner/co owner of my pet (s) account I understand and acknowledge that estimates are only provided if requested and it is my responsibility to ask for a written estimate prior to my pet (s) exam if needed(initial) As the owner/co owner of my pet (s) account I understand and acknowledge that I am responsible to submit my pet (s) insurance claim(s) and pay upfront for the visit regardless if claim is approved or denied(initial) Signature Date download pdf
