New Patient Form

If your pet is a new patient at our hospital, please fill out our New Patient Form using one of the options below.

OPTION 1
Complete Online

Complete and submit the form below.

OPTION 2
Print & Complete

Bring the completed form with you.

Download Form

OPTION 3
Complete on Arrival

If you prefer, you can complete the form when you get to our hospital.

New Patient Form

Please provide us with the following information.

Client Information

Owner First Name *

Owner Last Name *

Co-Owner / Spouse Name

Home Address *

City *

State *

Zip *

Email Address *

Call 1st Phone Number *

Call 1st Contact

Secondary Phone Number

Secondary Contact

Location *

Do you have a scheduled appointment? *

If yes, what is the date and time of your appointment?

Patient Information

Patient Name *

Type of Animal *

Breed *

Sex *

Birth Date / Age *

Color

Are vaccinations current? *

Reason for Referral (Primary Complaint) *

Please list any of your pet's drug allergies or special problems that we should know about. *

Primary Veterinarian Information

Clinic Name (If none, enter N/A) *

Doctor's Name

Have you heard about our hospital prior to this referral? *

If yes, how did you hear about us?

Did you bring x-rays, lab work or medical records from your veterinarian? *

Photography Release Form

Atlantic Coast New York Veterinary Specialists uses public social media forums, as well as other digital and print media to promote pet health, educate the community about our services, and share the faces and stories of our beloved patients.

Do you consent to having your pet's photo(s), first name, and medical information shared on our public social media forums, digital media and print media for those purposes?

Yes

Payment Information

I understand I am financially responsible to Atlantic Coast New York Veterinary Specialists for all charges. I understand that payment is due in full at the time services are rendered. I agree to pay all interest, collection, legal, attorney or court fees in the event it becomes necessary to pursue the account for collection. We accept cash, major credit cards and Care Credit. Unless specifically requested, all pets needed emergency care while staying in our hospital will be treated until the owner / agent can be contacted.

By submitting this form, I agree to the above.

Spam Blocker

Apply for CareCredit Financing

With CareCredit Financing, you can get your pet the veterinary care they need at Atlantic Coast New York Veterinary Specialists.

Learn More

New Patient Form

OPTION 1Complete Online

OPTION 2Print & Complete

OPTION 3Complete on Arrival

New Patient Form

Client Information

Patient Information

Primary Veterinarian Information

Photography Release Form

Payment Information

Apply for CareCredit Financing

OPTION 1
Complete Online

OPTION 2
Print & Complete

OPTION 3
Complete on Arrival