Catskill Veterinary Services, PLLC

230 Rock Hill Dr
Rock Hill, NY 12775

(845)796-5919

www.catskillvetservices.com


New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.You are welcome to also fill out our word document version of our new client form.   This form is found HERE

AUTHORIZATION

I assume complete responsibility for all charges incurred with the care of the animal(s).  I also understand that these charges will be paid at the time of completing my visit, and that a prepayment may be required for the hospitalization, treatment, or transport of a patient.  For all unpaid accounts, there will be a monthly finance charge of $6.00 or 10% interest rate.  For all returned checks, there will be a $40 processing fee in addition to the amount due on the account.  If accounts lapse for a period of 90 days, you will be subject to legal action.

 

Please take notice that there will be a $25 no show fee for any and all missed in hospital appointments.  For any missed house call appointments, the fee is $65. For any missed surgery appointment, the fee is $100.

 

We accept Visa, MasterCard, Discover Card, American Express, Scratch Pay, and CareCredit (ask about terms and conditions).


Thank you for your cooperation in letting us assist you.

New Client

Label
Name (required)
First Name (required)
Last Name (required)
Mailing Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
Physical Address (If different from your above address)
Street Address
City
,		State / Province
Zip / Postal Code
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Patient's Name (required)

Age: Years, Months

Type of Patient (required) :
Breed:

Sex: (required)

Male
Female


Neutered/Spayed

Neutered
Spayed


Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?

Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?

Yes
No


Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please check that you acknowledge fees and authorize treatment.

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