New Client Registration

Rocky Shores Veterinary Hospital, P.C.

341 Route 25A
Rocky Point, NY 11778

(631)209-2035

www.rockyshoresvet.com

Please note:

A valid form of identification (ie: driver's license) is required in order to complete registration

Please call the office at 631-209-2035 to schedule an appointment before submitting this form

Name (required)

First Name (required)	Last Name (required)

(required)

Male
Female

Date of Birth (you must be 18 years of age to register, otherwise your submission will be discarded) (required) :

Spouse/Partner

First Name	Last Name

Authorized Agent

First Name	Last Name

E-Mail Address :

Primary Contact # *(required)*
Phone Type	Phone Number (required)

Secondary Contact #
Phone Type	Phone Number

Previous medical records? (required)
(If possible, please bring a copy of your most veterinary recent visit.)

Yes
No

Please list name of pets here (required)

How did you "discover" Rocky Shores Veterinary Hospital? (required)
(If referred, let us know who we can thank!)

Word-of-mouth
Referral
Internet
Phone book
Community Fundraiser
Location/drive-by
Other (indicate below)

(required)
(A valid form of identification is required to complete registration)
I confirm that the information above is correct

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