Dr. Alana’s New Client Form

Dr. Alana's New Client Form

BEFORE FILLING OUT OUR NEW CLIENT FORM, PLEASE VISIT OUR WEBSITE TO VIEW OUR SERVICES AND PRICES TO MAKE SURE WE CAN ACCOMMODATE YOU AND YOUR PETS NEEDS. WWW.DRALANASVETERINARYCARE.COM
Owners Name *

First NameLast Name
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you live an apartment building or gated community? If yes, please give any pertinent details (gate code, intercom #, specific entrance, parking, etc). *
The above phone number is*

Cell phoneHouse phone
Method of preferred communication?*

EmailTextPhone
Please choose your preferred arrival time below. Due to the nature of being a mobile practice serving most of Suffolk County, we can not give exact appointment times. Therefore, our appointments are made as 4-5 hour time slots.

Your estimated arrival window begins at the time you select, e.g.:

(11am appointments - estimated arrival time is 11am-5pm).

(12pm appointments - estimated arrival time is 12pm-6pm).

(1pm appointments - estimated arrival time is 1pm-7pm).

(2pm appointments - estimated arrival time is 2pm-7pm).

(3pm appointments - estimated arrival time is 3pm-8pm).

(4pm appointments - estimated arrival time is 4pm-8pm).

We will contact you when we are on our way to you; usually about a half hour before we will arrive.

While we strive to be timely, in the case of an emergency or other unforeseen circumstance, we may need to ask you to adjust your appointment time. Please know that we only do this as necessary, and ask for your understanding, as we would do the same for your pet.
Please request a date and time slot. Mon, Tue or Thursdays appointments are booked 11am-5pm

PET INFORMATION

	First Pet	Second pet	Third Pet	Fourth Pet
Pets Name:
Species
Breed:
Color:
Birthday or approximate age:
Sex:
Fixed: Y/N
Weight:

Reason for visit: (for example: your pet needs vaccines, possible ear infection, skin problem etc) Please note: If your appointment is for a euthanasia please fill out our in home pet euthanasia request form only.***** *
ALL VISITS WILL REQUIRE AN EXAM
If you would like, please upload a picture of your pet(s). Upload up to 6 pictures below:

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Is your pet aggressive or nervous ? If yes please give additional information*** If your pet is unable to be handled, your pet may be prescribed medication at the first appointment to be given before a future appointment with an additional house call fee and exam fee of $258 *
Please describe in detail. Please note that your pet may be denied services if Dr. Alana or her staff feel unsafe. A house call visit fee of $238 will be charged to owner for our time driving to your home and time spent in the home.
Does your pet have a bite history? If yes please explain below.*
Please indicate if you feel Dr. Alana will need an assistant to handle your pet? If no, you must be willing and able to hold your pet safely for their exam, and any diagnostics or treatments, such as blood draws and/or injections. *
Name and phone number of previous Veterinarian: *
Please explain why you and/or your pet would prefer a house call visit: *
Has your pet had any previous serious illness, or serious surgeries? If yes please explain: *
Has your pet ever had allergic reactions to vaccinations and/or medications, food, or treats in the past? If yes please explain and list medication/food or vaccine:*
Please list all medications your pet is currently taking, as well as mg and frequency. Please include any preventatives and supplements. Mark N/A if none.*
Please upload pictures showing mg and doses of all medications pet is currently taking

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Will your pet need any refills on previous medications or prevention? (such as flea, tick or heartworm prevention, insulin, anti-inflammatories, pain medication etc.) If yes please name the medication, mg, quantity and frequency. Mark N/A if none. *
Any other information you would like to add about your pet or home?
Please upload any pictures that may help us treat your pet.

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We love to share our furry friends. Do you give consent for images and/or video of your pet(s) to be used on our website, social media pages, or other promotional materials? *
Please upload any medical/breeder/rescue records here:

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How did you hear about us?*

Google searchFacebook adFacebook groupFamily/FriendOther
Please tell us the name of the person/group who referred you (if applicable)
****If your appointment is for a cat, prior to our arrival they must be secured in a small room where it will be difficult for them to hide, such as a bathroom. Dr. Alana and her staff will not be responsible for catching your cat. If you are unable to handle your cat please call us to discuss other options before submitting this form. 631-464-1410. ****

Please note the $258 deposit will still be charged if your pet is unable to be examined for any reason.
If not uploaded above, please e-mail your pet's medical records to Lauritanodvm@gmail.com before your appointment so we may better serve you and your pet.
I understand that the house call fee minimum is and the initial consultation of $285 or $358 depending on location. (Follow up appointments will be $225 house call fee and exam) Any diagnostics, treatment and/or medication will be at an additional charge and the the full amount will be due at the time the services are performed and medications are dispensed. If you must change or cancel your appointment, 24 hour notice must be given. For all visits there is a $50 fee for change or cancellation within 24 hours of your appointment time, $200 fee within 12 hours of appointment time, and $285 fee when Dr. Alana is already driving to your home or there is no answer at your door. *

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You can find a comprehensive list of services and pricing on our website at Dralanasveterinarycare.com. Please note that your credit card will not be charged until your appointment is confirmed with one of our staff members. Your credit card will also NOT be saved at that time. You may see a pending charge for up to 6 days on your credit card if for some reason we decline your appointment. However the payment will not be processed until your appointment is confirmed.

A minimum deposit of $258 or $308 must be processed in order to confirm your appointment.

Please make your choices from below: YOUR CREDIT CARD INFORMATION WILL NOT BE SAVED FOR ADDITIONAL SERVICES. A SEPARATE INVOICE WILL BE SENT AFTER YOUR APPOINTMENT FOR ANY ADDITIONAL SERVICES. AT THAT TIME YOU MAY CHOOSE TO SAVE YOUR CARD ON FILE FOR FUTURE VISITS. *

House call visit with first consultation for central Suffolk NY Product Image

House call visit with first consultation for central Suffolk NYFurther diagnostics, medications, etc. will be an additional charge and will be due at time of appointment. Please note that your credit card will not be charged until your appointment is confirmed with one of our staff members.

$285.00

House call with first visit (west of route 110 or east of Riverhead) Product Image

House call with first visit (west of route 110 or east of Riverhead)Further diagnostics, medications, etc. will be an additional charge and be due at the time of appointment. Please note that your credit card will not be charged until your appointment is confirmed with one of our staff members.

$358.00

Dr. Alana's Pets Inner Circle Concierge Service e Product Image

Dr. Alana's Pets Inner Circle Concierge Service eThis is a monthly subscription that provides the following: Unlimited text/email support directly with Dr. Alana ; 10% off house calls, 1 monthly telehealth session, No $100 same-day fee (if available) cancel anytime. (Card will be charged $40 automatically every month.

$40.00 Quantity

Total

$0.00

Credit Card

Should be Empty:

Dr. Alana's New Client Form

If not uploaded above, please e-mail your pet's medical records to Lauritanodvm@gmail.com before your appointment so we may better serve you and your pet.

Credit Card