201-337-7090 (Call or Text) [email protected]

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New Client Form

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Registration

Name of Owner *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Alternate Phone

Email *

Spouse/Partner

Phone

Preferred Contact Method *

Phone
Email

How did you hear about us? *

Google
Facebook
Yelp
Sign / Walked by
Referral
Other

Who referred you, we'd love to thank them!

If Other, please explain

Patient Information

Pet's Name *

Species *

Cat
Dog
Other

If Other, please elaborate

Age

Date of Birth

Sex *

Female
Spayed Female
Male
Neutered Male

Breed

Color

List any known allergies

Other pets in the household? *

If yes, please list pet types

Do you have pet insurance? *

If yes, please let us know which company

Former Veterinarian Name/Hospital

Former Veterinarian's Phone Number

Please upload any of your pet's records that you may have

Click or drag files to this area to upload. You can upload up to 5 files.

Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment or hospital treatment. *

I have read and agree

I hereby authorize the release of my pet’s medical records to another facility (boarding/daycare, urgent care facility, etc.), should they be requested. *

Signature *

Date *

Phone

Numbers

Phone (Call or Text): 201-337-7090
Fax: 201-337-0515

Hours

Monday – Friday 8:30 am to 6:00 pm
Saturday 8:30 am to 12:00 pm
Sunday – Closed

Doctor hours are by appointment.

Address

86 Ramapo Valley Road
Oakland, NJ 07436

Have a question? Looking to make an appointment? Just want to say hello? We’re here for anything you need and will get back to you immediately. If this is an emergency, please call us immediately!

Name *

First

Last

E-mail *

Comment or Message *

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