Specialty Client / New Patient Registration Specialty Client / New Patient Registration Thank you for trusting in us and allowing us to provide specialty care for your pet today. Our goal is to provide your pet with high quality compassionate specialty care and to communicate thoroughly with you regarding our recommendations. Please do not hesitate to ask our specialists or other VMC staff any questions you may have. Name * Name First First Last Last Address * Address Street Street Apt/Suite Apt/Suite City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Email * Phone (home) * Phone (cell) * Are you over 18 years of age? * Yes No Pet Information Pet Name * Species * CanineFelineOther Gender * FemaleFemale (spayed)MaleMale (neutered) Breed * Color * Your check here authorizes us to send your pet's medical records to the above named veterinarian Authorize Age / Date of Birth * The Veterinary Medical Center does not receive funding from any state, county, or local programs. We are unable to provide billing services and must have a deposit prior to rendering services. Full payment is required upon receipt of service. We do not provide billing services, and we do not hold checks. We require a 75% deposit of the higher end of the estimate at the time of admission for hospitalization or outpatient treatment. We accept cash, checks, and credit cards. We offer a payment plan through CareCredit—a credit card that you must apply for and be approved. Please ask one of our staff about applying for CareCredit and the payment options that are available if you are interested. The doctors and staff are not authorized to make changes to the hospital’s payment policy. * I have read and understand the financial policies of the Veterinary Medical Center of CNY. I certifiy that I am the owner of or the agent of the owner of the aforementioned pet. I further understand that I agree to the terms of payment above and if I default on this agreement I may be subject to collection and all reasonable attorney's fees incurred. Briefly describe why your pet is here today * Your Pet's Veterinarian As a specialty referral center it is important for us to share our medical records with your primary care veterinarian. Please provide us with your veterinarians contact information so that we can send your pet's records to them in a timely fashion. Please select one option * My pet is an established patient of the veterinary hospital below My veterinarian has not yet seen this pet I do not have a regular veterinarian yet Veterinarian Name Hospital Name 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: By signing this form and providing your number you consent to receive email and/or SMS text messages from us. Message rates vary. Not all carriers are covered. Standard messaging and data rates apply. You may update your preference, and cancel your consent, by notifying us at any time or by replying CANCEL/STOP to any message you receive from us. 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
