New Veterinary Patient Form | Heart of Brooklyn Veterinary Hospital in Brooklyn

Owner Information

First Name: *

Last Name: *

Email *

Primary Phone *

Secondary Phone

Street Address: *

Address Line 2 *

City *

State *

Zip Code *

Secondary Contact

Who else is authorized to make decisions about your pet's healthcare?

First Name: *

Last Name: *

Phone *

Email *

Patient Information

Pet Name *

Species *

Breed: *

Sex *

Age / Date of Birth *

What is your pet's hair/fur coat color? *

Does your pet have a microchip identification? *

Yes

Where and how long ago did you acquire your pet? *

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Where has your pet received veterinary care in the past? *

Please list all Veterinary Practices and phone numbers where your pet has been seen in the past 24 months.

Media Release: Do you grant Heart of Brooklyn Veterinary Hospital permission to use your pet's images on our social media platforms? *

Yes

Medical Records

Please attach a photo of any relevant medical records.

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Behavioral Questionnaire

Does your pet show any reluctance to getting in the carrier or car? *

Yes

How and where does your pet travel in the car? (carrier, seatbelt, loose, etc.) *

Other:

Does your pet prefer: *

Female veterinary professional

Male veterinary professional

It doesn't matter

Does your pet have any allergies? If yes, explain. *

Does anyone else in your family have any allergies that we should be aware of? If yes, explain. *

How would you describe your pet around other animals and people? *

Does your pet have any sensitive areas that s/he does not like to have touched by you or others? *

Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (nail trims, weight, temperature, ear exam, blood draw) If so, how did your pet react? *

What are your pet’s favorite treats? (Please bring some to your next visit to our hospital): *

Does your pet like to play with toys? If so, what kinds? *

Has your pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did you experience? *

Anything else you would like us to know? *

Deposit Policy: For all new clients, we collect a deposit of $40, which is applied towards the cost of your exam when you arrive for your appointment. Should you need to cancel or reschedule your appointment, please do so at least 24 hours before your appointment time. Appointments that are cancelled with less than 24 hours notice, or an appointment which results in a no call/no show will result in the loss of your deposit, and will require an additional deposit for future appointments. Existing clients who cancel more than two (2) appointments in a year with less than 24 hours notice, or who no call/no show to more than two (2) appointments in a lifetime will result in deposits being collected for all future appointments moving forward. These deposits shall be applied towards the cost of services upon successful completion of these visits. *

I have read and understand.

Payment Policy: During your visits, you will be provided an itemized treatment plan and cost breakdown prior to any services being provided. Any and all costs approved by a client shall be paid at time of services or no later than the patient’s discharge from our facility. We accept Visa, Mastercard, Discover, Debit, Cash, and Care Credit. We do not offer any in-house payment plans. *

I have read and understand

Lateness/Tardiness Policy: We are passionate about offering the best possible care to you and your pet, just as we are passionate about providing for the pets that come before and after you. Because we operate on an appointment-based system, it is critical to our operations and to our other patients that we remain on schedule. Our high standard of care does not allow for us to rush appointments or perform abbreviated exams, and therefore it is crucial that you arrive at your appointment on time. Arriving more than ten (10) minutes late for your appointment will result in an automatic cancellation of this appointment, we are unable to make any exceptions to this rule. If you believe you will be more than ten (10) minutes late to an appointment, please call our practice so we may reschedule you. Clients who are more than ten (10) minutes late to two or more appointments in a calendar year will result in a non-refundable $40 deposit applied towards all future appointments.

I have read and understand

Client Code of Ethics: Everyone who works at Heart of Brooklyn Veterinary Hospital is here because we care deeply for the dogs and cats in our care and we are proud of the work that we do. We go to great lengths to show our clients the respect and dignity they deserve, and to build long-lasting and trusting relationships with our pet parents. If any of our staff members do not display these values, or if you have been harmed in any way by our staff, we ask that you please reach out to our Practice Manager so we may correct this situation. We have a zero tolerance policy for staff showing disrespect or harm to our clients, and we also have a zero tolerance policy for clients showing disrespect or harm to our staff. Any clients who demonstrate rude, aggressive, hostile, or inappropriate behavior towards anyone inside our premises will have their relationship with Heart of Brooklyn Veterinary Hospital terminated, and their medical records will be mailed to the address on file. *

I have read and understand

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New Patient Form - Fort Greene

Owner Information

Secondary Contact

Patient Information

Medical Records

Behavioral Questionnaire

New Patients Welcome