Patient Forms

New Patient Form

Welcome! If you’re planning your first visit to Pearl River Animal Hospital, we look forward to meeting you. To save time on your first visit, we encourage you to print and fill out our new patient forms below.

If you do not already have AdobeReader® installed on your computer, Click Here to download it now.

  • Download the necessary form(s), print it out, and fill in the required information.

  • Complete your forms and bring them in with you to your appointment
    ​​​​​​​

Hospital Admission Form

19 S Pearl St
Pearl River, NY 10965

Client's Name*:
Pet's Name*:
As the owner or agent of the of the above animal, I herby give my consent to Pearl River Animal Hospital to perform the following procedures:
Are there any additional concerns for your pet?
Are there any additional treatments we can provide your pet with today?
What is your pet's normal diet?
When was your pet last fed?

I authorize Pearl River Animal Hospital to provide veterinary service as needed for the well-being of my pet.
​​​​​​​
I understand that I, or my agent, assume financial responsibility for all services rendered, and payment is required when my pet is discharged.
​​​​​​​

Date
Best contact number:
Alternate/other number:
Staff initials:

*All animals admitted must be free of external parasites, any animal found to have fleas or ticks will be Treated at owner's expense.

Pearl River Animal Hospital​​​​​​​​​​​​​​

Dr. Diane Stenzier

Dr. Lisa Barnett

Surgery and Anesthesia Consent Form

Pearl River Animal Hospital​​​​​​​​​​​​​​

19 S Pearl St
Pearl River, NY 10965

New Patient & Client Information Sheet

Welcome to Pearl River Animal Hospital. So, we may provide you with exception service, please share information about you and your pet. Our goal is to provide our clients with the best, compassionate veterinary care.
​​​​​​​

Patient Information
Pet's Name:
Sex:
Neutered or spayed?
Species:
Is your pet microchipped?
Do you have pet insurance?
Pet's Date of Birth:
Breed:
Color:
Reason for bringing pet in:
Does your pet have any allergies, special medications, or health problem we should know about?
If Yes, What?
What type of food does your pet eat?
Treats?
Do you have other pets?
Dates of last vaccinations:
Dogs:
Date of Rabies Vaccine:
Date of DA2PP Vaccine:
Date of Lyme Vaccine:
Date of Leptospirosis Vaccine:
Date of Kennel Cough Vaccine:
Where were the most recent vaccinations given?
Heartworm Test Date:
Heartworm Test Result:
Is your dog on heartworm preventives?
Cats:
Date of Rabies Vaccine:
Date of FVRCP Vaccine:
FIV/FeLV Test Date:
FIV/FeLV Test Result:
Who is your previous veterinarian?
Phone:
Patient Information
First name:
Last name:
Patner first name:
Patner last name:
Address:
City:
State:
Zip
Home Phone:
Work Phone:
Cell
Email address:
Employer:
Preferred method of contact?
How did you become aware of our hospital?
Referral:
Who can we thank?

Payment is required when services are rendered. For your convenience, we accept cash, MasterCard, Visa, Discover and American Express. I verify that all the information provided is accurate, and I am the owner of the per listed. I hereby authorize. The vetenarian to treat the pet described, I also understand that charges will be paid at time of services rendered.
​​​​​​​

Date
Is there another authorized person/agent on our behalf? Please list their name:
Client:
Patient:
Date

Checklist for Wellness Appointment

Verify client contact informnation to ensure it is current (name, address, phone, e-mail

Age:
Weight:
Temperature
Pulse
Respiration
Sex
I HAVE READ AND FULLY UNDERSTAND THIS SURGERY AND ANESTHESIA CONSENT FORM.
Best contact number:
Alternate/other number:
Neutered or Spayed
Reason for today's visit
Is there anything else you want to be sure to discuss with the doctor today?
Diet:
What food are you feeding?
How much do you feed?
How often do you feed?
What kind of treats / snacks / table scraps / chews do you give your pet?
Current medications
What heartworm preventative do you give your pet?
What day of the month do you give your pet's heartworm preventative?
What flea/tick preventative do you give your pet?
How often?
Does your pet have a microchip?
What dental care do you provide for your pet at home? (check all the apply)
Are other pets living at your home?
Species
Pet name
Species
Pet name
Does your pet need a nail trim today?
Has your pet been seen elsewhere for medical care since we last saw him/her?
When, where and what was done?
Any bumps or skin masses that the doctor should be aware of?
When, where was it seen, any changes?
Does your pet have any of these symptoms? (check all the apply)
Staff's initials:
Roya1234 none 9 AM - 5 PM 9 AM - 5 PM Closed 9 AM - 5 PM 9 AM - 5 PM Closed - Hours to be Extended Soon Closed veterinarian # # #