 info@rocpetrehab.com … 585-360-2288 … …

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Client/Patient Information Form

Please complete the form below.

Please complete our Rehab Referral Form

All fields marked with * are required and must be filled. Thank you for your referral!

Owner's Name *

First

Last

Co-Owner's Name

First

Last

Primary Owner Cell *

Co-Owner Cell

Primary Owner Home Phone

Co-Owner's Home Phone

Primary Owner Work Phone

Co-Owner's Work Phone

Primary Owner 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/are designated as an 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 *

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 ROC Pet Rehab, 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.

Please upload previous medical records and vaccine history:

Click or drag a file to this area to upload.

Signature *

roc

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Contact

P: 585-360‑2288
F: 585-360‑2634
E: info@rocpetrehab.com

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Hours

Mon: Closed
Tue - Wed: 8 a.m. – 6 p.m.
Thu & Fri: 8 a.m. – 5 p.m.
Sat: 8 a.m. – 2 p.m.
Sun: Closed

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Location

580 White Spruce Blvd Suite 1,
Rochester, NY 14623

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