Steinway Court Veterinarian - New Client Registration

Online Forms

New Client Registration - online or pdf
Appointment Request - online
Customer Satisfaction Survey -
online
Boarding Form - pdf

To ensure the best care possible for your pet, please take the time to complete this form so we have as much information as possible. When done, click submit to send the form information to us.

Your Name
Street Address
City, State, Zip
Home Phone
Work Phone
Cell Phone
E-mail
Spouse or Co-Owner Name
Spouse or Co-Owner Phone
Please name the last veterinary facility you visited
Whom may we thank for your referral? (we love to thank them)
How did you hear about us?
Patient (Pet) Information:
Pet Name
Species
If Other Species
Sex	Male Female
Neutered/Spayed?	Yes No
Breed
Color
Birthday (age)
Microchipped?
Last Known Vaccinations & Date
Date of Last Dental Cleaning
Is your pet taking Heartworm Preventative?	Yes No
Date of Last Heartworm Test / Fecal Exam:
Existing Medical condition(s)
Please tell us the reason for your visit
Disclaimer (read-only)	To prevent the spread of infectious diseases and parasites, hospitalized and grooming pets must be current on all vaccinations and free of internal and external parasites. FULL PAYMENT IS DUE AT THE END OF EACH VISIT. THANK YOU! We accept cash and all major credit and debit cards. Unfortunately, we can not accept checks. If legal collection of monies is required, all fees incurred by our office will be charged to your account.

When you are finished, click submit to send the form information


(718) 728-2822 info@steinwaycourtvet.com 32-41R Steinway Street Long Island City, NY 11103 map>		©2012 Steinway Court Veterinarian, all rights reserved \| designed by Animal Doctor Design Home \| Services \| Our Clinic \| Testimonials \| Pet Care Information \| Pet Resources \| Contact Us New Client Registration \| Appointment Request \| Customer Satisfaction Survey \| Boarding Form