Patient Check-In Questionnaire

We look forward to seeing you and your pet on their upcoming visit. Please help us make this process a little easier by filling out this check-in questionnaire. Due to COVID19 social distancing restricionts all of our appointments are done with curbside check-in.

When you arrive for your appointment you have two options for check-in:

Call (845) 354-1800 to check-in, notify the reception team that your pet has arrived for their appointment, and give your parking space number.

Text COMING SOON with your pet's name and parking spot number to get checked-in.

Once our reception staff have your pet checked in a technician will be out to bring your pet in to be seen.

PLEASE REMAIN AT THE CLININC WHILE YOUR PET IS BEING SEEN.

Location of Appointment

Date of Appointment

Date

Time of Appointment

: Hour Minutes AM/PM Option

Owner's Name: *

First Name Last Name

Pet's Name *

Pet's Species *

Canine Feline

What is the best number to reach you while at the clinic? *

Email *

example@example.com

Would you like your invoice emailed or receive a physical copy when your pet is brought back to your vehicle? *

Email Invoice Physical Copy of Invoice

Please provide your current mailing address. We are working on updating our records and this would be a great help to our staff! *

Street Address

Street Address Line 2

City State

Zip Code

Has your pet been around anyone exhibiting cold, flu or upper respiratory infection symptoms? *

Yes No

Presenting Complaint *

Is your pet fearful or do they need a muzzle? *

What medications is your pet using, this includes flea/heartworm preventatives or supplements? *

Do you need any medications refilled? *

Yes No Not on any Medication

Which medication(s) you need?

Are you familiar with our online pharmacy? To have meds shipped directly to your home *

Yes No

What is the name of your pet food and how much do your feed per day? *

Is your pet eating/drinking normally? *

Yes No

If answered No, to the above, what has changed?

Does your pet have any of the following: *

Coughing Sneezing Vomitting Diarrhea None of the Above

If yes, how long has it been occurring? *

Is your pet acting normally? *

Yes No

If No, to the above, what has changed?

Is your pet on any supplements? i.e. Fish Oil, Probiotics, CBD, etc. *

Yes No Unsure

Are there other pet's in the house? If yes pleas note:

Are you needing vaccinations to be able to board your pet or take them to the groomer? *

Yes No

Is your cat an indoor or outdoor cat? *

Indoor Outdoor Both

Please note your dog's exercise activity: *

Example: leash walks, running with owner, plays in backyard

Have you heard about our VIP Well Plan Program? *

Yes No

If No, Would you like info on our VIP Well Plan Program?

Who do you have for pet insurance? *

Would you like an estimate before services are performed? *

Yes No Depends on Diagnosis

Any other concerns? *

At Rockland Veterinary Care we love our patients and sometimes we want to take and share their photos on our social media sites, website, print or other advertising. In order for us to share their pictures, we need your permission to do so. Please click your choice below.

Yes, Rockland Veterinary Care may take and publish photos of my pet. No, Rockland Veterinary Care may not take and publish photos of my pet.

Consent

I, the undersigned owner or agent of the owner, hereby consent to the examination of my pet by Rockland Veterinary Care (RVC). I agree that after consultation with me, the hospital's Doctors may prescribe medication for, treat, hospitalize, anesthetize and.or perform surgery on my pet. I understand that no guarantee can be made as to the outcome of treatment and that I am encouraged to discuss any concerns I have about the risks of treatment with the attending Veterinarian before any procedures or treatment is initiated.

I understand that a treatment plan including an estimate of the costs for Veterinary Services will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered and during my pet's ongoing medical treatment.

I hereby authorize the name(s) above to make financial and medical decisions for the patient listed. I understand the professional fees are to be paid at the time services are rendered and a deposit is required on all pets admitted to the hospital.

I understand that I (the owner or agent) am financially responsible to RVC for all charges relating to this patient. I have read and agree to the treatment authorization. I have also read and accept the financial obligations.

Client Rights:

As a valued client at Rockland Veterinary Care, you have the right to-

receive respectful and considerate care for your pet in a safe setting
to be provided the name of the treating veterinarian and receive information about your pet's health status by the veterinarian managing your pet's care
to receive as much information about any proposed treatment or procedure as you need to make an informed medical decision
to participate actively in decisions regarding your pet's medical care
to establish an advance health care directive for your pet
to seek a second opinion with another veterinarian at RVC or another facility if pet is stable to be transferred
to refuse treatment and to be informed of the medical consequences of such refusal
to examine and receive an explanation of charges related to your pet's care
to designate authorized caretakers or persons who can make medical decisions in your absence
to receive free copies of your pet's medical records or to have those records forwarded to another veterinary provider.

Client Responsibilities:

Our medical team practices medicine in the best interest of the individual patient and cannot practice medicine based on requests or demands for particular medication, tests or treatments. We are committed to the future of veterinary professionals and as such, employ licensed DVM associate veterinarians. All staff at RVC have a right to be treated with respect in the workplace. RVC reserves the right to terminate a relationship with any Client who's abusive (including yelling, demeaning statements or threatening language towards Veterinarian, staff, other clients or vendors); who after making an informed decision disputes medical outcomes; who repeatedly misses appointments or repeatedly cancels same day; or who does not pay for services.

I HAVE READ AND UNDERSTAND THIS AUTHORIZATION AND CONSENT FORM *

Yes, I give RVC consent to treat my pet No, I do not give RVC consent to treat my pet

Signature *

Clear