Current Client Appointment Request form

Current Client Appointment Request form

Your pet must have already been seen by Dr. Alana at least once to fill out this form. If you are a new client please fill out the New Client Form.
Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Phone number above is*

Cell PhoneHouse phone
Preferred method of communication*

TextEmailPhone
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet's name(s) : *
Is this a new pet we have not seen before?*

Pet Information (If we have not seen them before)

	First Pet	Second Pet	Third Pet
Pet's Name
Species
Breed
Color
Birthdate or approximate age
Sex
Fixed? Y/N
Weight (approximate)

Reason for visit:*
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 your preferred date and time. We see appointments on Monday, Tuesday, and Thursdays. 11am-5pm
I understand that the house call fee minimum for current clients is $255. 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 $258 fee when Dr. Alana is already driving to your home or there is no answer at your door.You give permision for Dr. Alana Lauritano to handle, exam, and treat your pet.
Signature

Clear

My Products*

House call visit with Exam Central Suffolk (Current client only)

$265.00

House call visit with exam (west of Route 110 or east of Riverhead)

$315.00 Quantity

House call visit with exam Central Suffolk Current Client CONCIERGE CLIENTS ONLY

$225.00 Quantity

Total

$0.00

Credit Card

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