CARE Pet Therapy New Patient Request CARE Pet Therapy New Patient Request Please fill out this form completely. You will be contacted once we receive your form with information about the scheduling an appointment. Name * Name First First Last Last Email * Phone * Pet Information Pet Name * Have you been seen at CARE Pet Therapy or Veterinary Medical Center before with this or another pet? YesNo Pet's Age * Pet's Species * Pet's Breed * Brief description of pet's problem * Primary Family Veterinarian VMC Veterinarian/Specialist (if any) Is there anything else you wish to share with us today? Preferred Pharmacy We may need to prescribe medications that you will need to have filled at a local pharmacy. Please let us know which pharmacy you would prefer to use. Name Phone Address / Location Authorizations Messaging I can receive text messages at the following number: I can receive text messages at the following number: Media We enjoy sharing photos and videos of our patients and their families on social media and occasionally on print materials, advertising, and educational material for the hospital. However, we will never do so without your consent. You understand that Veterinary Medical Center of CNY may take and use photographs and/or videos of you and/or your pet with or without your name and for any lawful purpose, including education, publicity, illustration, advertising, and web content. * I understand If you prefer NOT to have you or your pet photographed or recorded on video, please select one or both of the options below: Veterinary Medical Center of CNY may NOT take photos and/or videos of my pets Veterinary Medical Center of CNY may NOT take photos and/or videos of me Captcha If you are human, leave this field blank. Submit
