SCVH New Client Registration

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"Because Every Family Member Deserves a Great Hospital"
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Thank you for choosing to partner with Rockland Veterinary Care when seeking the best care for your companion(s).

Rockland Veterinary Care is a full-service, small animal veterinary hospital. We are committed to providing personal, comprehensive care to each patient and client through companion animal medical, reproductive, surgical, and dental services.

Top quality patient care is one of our highest priorities, as is respecting the relationship between you and your pet. We treat your pet as we would our own. Our doctors and support staff are committed to providing personal attention to the unique concerns of each pet owner. As your companion(s)'s health care partner, we strive to help you make informed and compassionate choices for their care.

Our small animal surgery and dental services emphasizes client education alongside compassionate patient care. We work to create a healthly and calm environment for your pet(s)'s medical experience and rehabilitation.
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Location of Appointment
North Rockland
Pomona
Hudson Valley
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Date of Appointment
Date
Year
Month
Day
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Time of Appointment
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Hour
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40
50
Minutes
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AM
PM
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Owner's Name:* This field is required.
First Name
Last Name
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Email Primary* This field is required.
example@example.com
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Phone Number (Main Cell)* This field is required.
Area Code
Phone Number
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Phone Number Secondary
Area Code
Phone Number
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Preferred Method of Contact* This field is required.
Main Phone (Cell)
Secondary Phone
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Marital Status* This field is required.
Single
Married
Divorced
Widowed
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Owner's Date of birth:* This field is required.
The Controlled Substance Utilization Review and Evaluation System (CURES) was certified for statewide use by the Department of Justice (DOJ) on April 2, 2018. It requires that a date of birth be kept on file for Adults 18 and over in the event that a controlled substance is prescribed. Visit www.mbc.ca.gov/CURES for detailed information regarding CURES 2.0
Day
Month
Year
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Partner or other authorized agents name:
First Name
Last Name
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Additional person's relation to you
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Additional person's phone number:
Area Code
Phone Number
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additional person's email:
example@example.com
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Do you authorize the above provided Partner/Co-Owner to make urgent decisions if you are unreachable?
Yes
No
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Current Pet Insurance Provider
Not applicable
Trupanion
Nationwide
Other
Interested but not sure who to go with, need more info
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Upload Blank Insurance Form
Drag and drop files here
Select files to upload
Max. file size: 1.0MB
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Pet's Name:* This field is required.
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Pet's Age/Date of Birth:* This field is required.
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Type of Pet* This field is required.
Canine
Feline
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What Breed and Color is your Pet?* This field is required.
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Pet's sex:
Male
Female
Neutered Male
Spayed Female
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Do you have additional Pets?
Yes
No
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Pet's Name:* This field is required.
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Pet's Age/Date of Birth:
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Type of Pet* This field is required.
Canine
Feline
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What Breed and Color is your Pet?* This field is required.
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Pet's sex:
Male
Female
Neutered Male
Spayed Female
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Previous Veterinarian's Name
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Initial Presenting Problem/ Special Needs/ Concerns:* This field is required.
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Would You like an estimate Before any services are performed?
Yes
No
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WOuld you like information on our Vip well plan? Which offers significant savings every year
Yes
No
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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.
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Signature* This field is required.
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