Welcome to East Hampton Veterinary Group
We would like to thank you for giving us the opportunity to care for your pet. We will be more than happy to answer any questions you have about your pet's health. To ensure the best care for your pet, please take the time to fill out this form completely. Thank you!
Owner Name
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Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
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Please enter a valid phone number.
Email Address
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example@example.com
How did you hear about us?
Yellow Pages
Sign
Internet
Recommended By
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Pet Information
Pet Name
Species
Dog
Cat
Other
Breed
Color
Birth Date
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Month
-
Day
Year
Date
Check All That Apply
Male
Neutered
Female
Spayed
Previous Veterinarian Information
Please Check Any Symptoms or Problems That You Have Noticed About Your Pet
Behavior Problems
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Eye Bulging or Bloodshot
Gagging
Lack of Appetite
Limping
Loss of Balance
Scooting
Scratching/Itching
Seems Depressed
Shaking Head
Sneezing
Thirst and/or Increased Urination
Vomiting
Weakness
Other
Type Of Diet/Frequency
Medications/Supplements
Flea/Tick Prevention
Heartworm Prevention
Authorization
I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet. I assume responsibility for charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and a deposit may be required for treatment.
Client/Owner Signature
Financial Policy
Thank you for choosing East Hampton Veterinary Group. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. East Hampton Veterinary Group requires payment in full at the end of your pet's examination and/or at the time of discharge.Payment Options: Cash, Check, Visa, MasterCard, American Express, Discover, and CareCredit. Additional Policy Information: East Hampton Veterinary Group charges for returned checks. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.
Client/Owner Signature: By signing you agree to the foregoing terms of payment.
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