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Urgent Care Client/Patient Information

Name: Pittsford Animal Hospital
Address: 2816 Monroe Ave., Rochester, NY, 14618, United States
Telephone: 585-271-7700
Price range: $

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Urgent Care Client/Patient Information
Form

Please complete our Urgent Care Client/Patient Form. All fields marked with * are required and must be filled.

Owner's Name *

First

Last

Co-Owner's Name

First

Last

Primary Owner Cell *

Co-Owner's Cell

Primary Owner Home Phone

Co-Owner's Home Phone

Primary Owner Work Phone

Co-Owner's Work Phone

Email *

Co-Owner's Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How would you prefer we contact you?

Email
Phone

Best number to contact you *

The following individual(s) is designated as alternate to give consent for services in my absence. The designation remains in place until the hospital is otherwise notified. As the owner, you are still responsible for any charges incurred by the consent given by the alternate individual.

Name

First

Last

Phone

Have you been to a veterinarian before?

Yes
No

If yes, who?

How did you become aware of our hospital?

NOTE: For the safety of all animals here, it is our policy that all animals be up to date with their vaccinations in order to be hospitalized or boarded.

Patient 1:

Pet Name *

Species *

Breed *

Color *

Sex *

Male
Female

Spayed/Neutered? *

Yes
No
Unsure

DOB or Approximate Age *

Add another pet?

Yes
No

Patient 2:

Pet 2 Name *

Species *

Breed *

Color *

Sex

Male
Female

Spayed/Neutered?

Yes
No
Unsure

DOB or Approximate Age *

Add another pet?

Yes
No

Patient 3:

Pet 3 Name *

Species *

Breed *

Color *

Sex

Male
Female

Spayed/Neutered?

Yes
No
Unsure

DOB or Approximate Age *

Add another pet?

Yes
No

Patient 4:

Pet 4 Name *

Species *

Breed *

Color *

Sex

Male
Female

Spayed/Neutered?

Yes
No
Unsure

DOB or Approximate Age *

If you currently have a primary veterinarian, Pittsford Animal Hospital will not see your pet(s) for wellness and follow-up care. It is Animal Urgent Care’s policy not to accept any patients that are seen during urgent care hours as long-term general practice patients. I, the undersigned, am at least 18 years of age and hereby state that I am the owner/caregiver of the above-specified animals.

I hereby give consent for the use of any images of my pet, taken by Pittsford Animal Hospital, in any and all marketing materials, including, but not limited to: the website, social media accounts, and digital/print promotional materials. *

Yes
No

In the event that payment is not received and my account is placed for collection, I agree to pay service charges in the amount of 1.5% per month (18% per annum) in addition to the amount.

Signature *

DOWNLOAD APP

Ready to begin earning rewards?

Click the buttons below to download our app from the App Store or Google Play.
Click the “Log in” button on the right-hand corner to create your account.
Use the email address on file with us and a password of your choice.
You will then receive a confirmation email to verify your account.
Open the email and click the “Verify your email address” button.
You will automatically receive your first loyalty stamp once your email has been verified.
Your pet information will sync with our system and show up in the app the next day.

Have questions about our app? Call us for more information!

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Urgent Care Client/Patient Information

Urgent Care Client/Patient Information Form

Urgent Care Client/Patient Information
Form