Oath Animal Hospital New Client Registration Form

New Client Registration Form
🏡 Client Information
Name*

First NameLast Name
Address*

Street Address

Apartment # (if applicable)

CityState

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email*
example@example.com
Is anyone else authorized to decide about your pet's healthcare?*

YesNo
Their Name*

First NameLast Name
Their Phone Number*
Please enter a valid phone number.
How Did You Hear About Us?*

Referred by FriendFollowing Dr. FunkBest of Long IslandTownhall New Mover MailerInternetDrove/Walked By, Live in the AreaPosh PetsSocial MediaOther
Which Friend or Client?*
So we can thank them!
🐶 Pet Information 🐱
Pet's Name*
Date of Birth*
mm/dd/yyyy
Is this age an estimate?*

YesNo
Species*

DogCat
Breed*
(examples: Shih Tzu, Dachshund, Mixed, Persian, Domestic Shorthair cat, Domestic Longhair cat)
Sex*

MaleFemale
Has your pet been spayed/neutered?*

YesNo
Predominant Colors &/or Identifying Markings*
Is your pet microchipped?*

YesNo
In the last 12 months, has your pet had a complete physical examination?*

YesNo
In the last 12 months, has your pet remained up to date on vaccinations?*

YesNo
Do you carry health insurance for your pet? Oath Animal Hospital advocates the use of Pet health insurance.*

YesNo
Please upload a photo of your pet for our records.

Cancelof
📸 Media Consent Policy
I hereby grant to Oath Animal Hospital and its agents, and assign the unlimited right to use my &/or my pet's name, images, and recordings of me in any format or medium to announce and publicize the hospital, its programs, and its affiliates. Oath Animal Hospital respects your privacy & will NOT use any sensitive human data such as personal details, phone numbers, emails, etc. Therefore, I consent to the distribution of that information and images by publications, broadcast, or any other means of distribution.
Media Consent Policy 📸 Please select*

AcceptDo not Accept
Media Consent Acknowledgement*

Clear
Initials
✍🏼 Dictation Policy
Our veterinary services utilize Scribblevet, a SOC 2 Type 2-compliant tool from Kairo Care, Inc. that meets the gold-standard certification for data security. Scribblevet records your pet's appointments to enhance clinical documentation. If you prefer not to be recorded, please notify the team in the exam room.
Dictation Policy Acknowledgement*

Clear
Initials
📆 Missed Appointment Policy
Missed appointments, defined as those not canceled or rescheduled with at least 24 hours’ notice, are subject to a $25 Missed Appointment Fee. We understand that emergencies may arise, and we ask that you contact us as soon as possible if you are unable to make your scheduled appointment. Repeated short-notice cancellations and/or missed appointments will result in a $55 non-refundable deposit required when booking future visits and/or limitations on scheduling non-emergency appointments.
Missed Appointment Acknowledgement*

Clear
Initials
Financial Policy
Payment is due in full at the time services are performed. Should your pet require admission to our hospital, we require explicit authorization from you before any care can be administered. Please understand that treatment cannot commence until you have confirmed your consent by (1) signing the client consent form and (2) providing an initial deposit equal to 50% of the upper end of any estimated costs. We accept payments through major credit cards, CareCredit, and ScratchPay. Personal checks (excluding business or money market checks) are also accepted, provided you present a valid driver's license, non-driver identification card, or military identification with a Social Security number. When paying by check, you authorize the hospital to process an electronic fund transfer (EFT) from your account for the same amount as the check, typically within 24 hours. All checks are subject to check guarantee services, and a $50 fee will be charged for checks drawn against insufficient funds. Please note that we do not extend credit or offer billing for services. Unpaid invoices may be sent to collections after 45 days unless alternative arrangements have been documented. Your initials below indicate your acknowledgment and acceptance of our hospital's financial policy.
Financial Policy Acknowledgement*

Clear
Initials
Please upload any medical records or documents you wish to share.

(Medical Records, Vaccine History, other relevant medical documents)
Cancelof
Signature*

Clear
Date*

MonthDayYear
Date
Still have questions? Please call us at 516-951-0254.
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New Client Registration Form

🏡 Client Information

🐶 Pet Information 🐱

📸 Media Consent Policy

✍🏼 Dictation Policy

📆 Missed Appointment Policy

Financial Policy