Your Client Care Coordinator will let you know which of the following forms need to be completed in advance of your pet's appointment at Veterinary Medical Center of Long Island.

Please be sure you have also completed the New Client Registration Form in advance of your first appointment.

Dermatology
Ophthalmology
Physical Rehab

Dermatology New Client Form

Owner Information

First Name *

Last Name *

Phone Number *

Your Email *

Would you like to receive updates, news and articles via Email? *

Yes

How did you hear about us? *

Veterinarian

Yellow Pages

Sign

Friend

Internet Search

Website

Pet Information

Pet's Name *

Breed *

Canine or Feline *

Canine

Feline

Other

Sex *

Neutered Male

Intact Male

Spayed Female

Intact Female

Age *

Color *

Weight *

Skin Problems

What skin problem are you bringing your pet in for? *

How old was your pet when the skin problem first started? *

Did the problem start suddenly or gradually over time? *

Suddenly

Gradually

Unsure

Is the problem year-round or intermittent? *

All Year Round

Intermittent

Unsure

Is the problem worse during certain times of the year (Seasonal flare-ups)? *

Yes

Unsure

Has your pet ever had an ear infection? *

Yes

Unsure

Is your pet itchy (this includes any licking, chewing, rubbing, biting, or scratching)? *

Yes

Unsure

Rate your pet’s level of itch on a scale of 0 (no itch) to 10 (your pet’s most severe itch). *

List the locations on your pet’s body where they are itchy *

What did you notice first? *

Skin Lesions

Itch

Both

Medications

List ALL medications your pet is CURRENTLY taking (including any topicals, supplements, or medications for other conditions not related to the skin). Indicate the response to these treatments if known.

Current Medications *

List PREVIOUS medications used to treat your pet’s skin/ears (including any topicals or supplements). Indicate the response to these treatments if known.

Past Medications *

What flea/tick prevention are you using? *

When is the flea / tick prevention given?

Year Round

Seasonally

What heartworm prevention are you using? *

When is the heartworm prevention given?

Year Round

Seasonally

Other Household Pets

What other pets are in the household? *

Are the other pets primarily?

Indoor

Outdoor

Both

Are the other pets in the household receiving flea/tick prevention?

Yes

Unsure

If yes, what type?

Does your pet have contact with any animals outside of your home? (list location and types of animals) *

Do any other pets or people in the household have skin problems? *

Yes

Unsure

Diet & Other History

What do you feed your pet (include treats, chews, table food, etc.)? *

Does your pet have a sensitive stomach associated with feeding different types of food (ex. vomiting, diarrhea, etc.)? *

Yes

Unsure

Have different diets been tried as treatment (list brand name & duration given)? *

Does your pet have any travel history (list location)? *

List any other diagnosed medical illnesses. *

Consent

Your First & Last Name *

Today's Date *

Authorization *

By submitting this form, I hereby authorize the veterinarian to examine my pet and I understand that the initial consult and starting tests will total approximately $ 679.00 for my pets first visit with the Dermatology Service and I assume responsibility for all charges incurred. Additionally, if my pet should require further testing or hospitalization, I understand that a deposit will be required. I also understand that charges are to be paid in full upon completion of services. Should it be necessary to settle my account through a collection agency or attorney, I agree to pay any and all interest, collection costs, and legal fees.

Please Note: We do not accept checks. Our acceptable forms of payment are Visa, Master Card, Discover, Amex, Care Credit, Cash and Debit.

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Ophthalmology New Client Form

Owner Information

First Name *

Last Name *

Email *

Phone *

Date *

Pet Information

Pet's Name *

Species *

Dog

Cat

Other

Please answer these questions to the best of your knowledge so we may serve you and your pet better.

What is your pet’s problem with its eye/eyes? Please check all that apply. *

Cataracts

Cherry Eye

Decreased Vision

Eye Discharge

Pain

Eyelid Mass

Grey Coloration

High Pressure

Injury

Redness

Scratch

Squinting

Eye Masse

Don’t Know

Other

If other, please describe.

How long ago did you first notice the problem with the eye/eyes? (eg. hours, days, weeks, years, since birth, don't know) *

What previous medical problems has your pet had? Please check all that apply. *

No Significant Medical History

Allergies

Coughing

Diabetes

Kidney Disease

Sneezing

Vomiting

Arthritis

Cushing’s Disease

Diarrhea

Nasal Discharge

Thyroid Hormone High

Weight Gain

Cancer

Dental Disease

Heart Disease

Seizures

Thyroid Hormone Low

Weight Loss

Please describe other medical issues we should be aware of: *

What medications does your pet currently take? Please include all medications. *

Do you feel that any current medications have helped your pet? *

Yes

Unsure

If no, please explain:

Do you feel that your pet will allow you to give eye drops or apply eye ointment? *

Yes

Unsure

Has your pet ever traveled outside of New York State? *

Yes

Unsure

If yes, when and where did your pet travel?

Is your pet an indoor or outdoor pet? *

Strictly indoors

Indoors mainly, but also on porch

Indoors and outdoors

Outdoors mainly, but with shelter

Is your pet up-to-date on vaccinations? *

Yes

Unsure

Consent

Your First & Last Name *

Today's Date *

Authorization *

By submitting this form, I hereby authorize the veterinarian to examine the above described animal. I assume responsibility for all charges incurred in the care of this animal. I understand that a deposit will be required before all procedures and hospitalized animals. I also understand that charges are to be paid in full upon completion of services. Should it be necessary to settle my account through a collection agency or attorney, I agree to pay any and all interest, collection costs, and legal fees.

Please Note: We do not accept checks. Our acceptable forms of payment are Visa, Master Card, Discover, Amex, Care Credit, Cash and Debit.

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Physical Rehabilitation New Client Form

Owner Information

First Name *

Last Name *

Phone *

Email *

How did you hear about us? *

My Veterinarian

A friend

I found you on the internet

Other

If other, please describe:

Pet Information

Pet's Name *

Breed *

Age / Birthdate *

Gender *

Neutered Male

Intact Male

Spayed Female

Intact Female

Species *

Dog

Cat

Other

Coloring *

Regular Veterinarian & Diagnostics

We need this information to obtain your pet's medical history and to send records after the evaluation.

RDVM Name *

Clinic Name *

Clinic Phone Number *

If you have had any diagnostics performed within the past year (ultrasounds, radiographs, bloodwork, etc.), please describe.

Pet Condition

How has your pet been feeling lately? Any coughing, vomiting, diarrhea, decreased appetite, pain, etc. *

Does your pet have a specific medical condition that you would like to address with rehab (eg. degenerative myelopathy, intervertebral disc disease, osteoarthritis, etc.) *

Is your pet recovering from a medical procedure? *

Post-Op Surgery (orthopedic/neurologic)

Arthritis/Geriatric Care

Conditioning for competition or performance (agility, herding, search & rescue, etc.)

Other

If other, please specify

What is your pet's current activity level (eg. walk length or duration, frequency of walks)? *

What is your home environment like? *

Stairs

Hardwood Floors

Carpet

Elevated Food Bowls

SUV, truck or other large vehicle

Other

If other, please describe.

What other pets do you have at home? Please include species and age. *

Diet & Medication

What food are you currently feeding your pet? Please include brand name, kibble/canned, amount and frequency. *

Please list any medications (including strength and frequency it is given) that your pet is currently taking. This should only include medications requiring prescription from a veterinarian. *

Please list any supplements that your pet is currently taking .This should include any supplements (like fish oils) that can be purchased over the counter. *

Are you interested in discussing supplements or nutrition/diet? *

Yes

Unsure

Does your pet have any food allergies or dietary restrictions (eg. Grain-free, raw diet, allergies to certain proteins) *

What are your goals and expectations of rehab? *

Please include any other information that was not addressed in the questions above:

Consent

Your First & Last Name *

Today's Date *

Authorization *

Please Note: We do not accept checks. Our acceptable forms of payment are Visa, Master Card, Discover, Amex, Care Credit, Cash and Debit.

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New Client Specialist Forms

Dermatology New Client Form

Owner Information

Pet Information

Skin Problems

Medications

Other Household Pets

Diet & Other History

Consent

Ophthalmology New Client Form

Owner Information

Pet Information

Consent

Physical Rehabilitation New Client Form

Owner Information

Pet Information

Regular Veterinarian & Diagnostics

Pet Condition

Diet & Medication

Consent

Caring for Pets on Long Island