Emergency
Appointment Check in
516-883-2000
About
Services
–
Medical
Wellness
Surgical
Dental
Vaccinations
Orthopedic
–
Spay/Neuter
Microchipping
Blood Tests
Acupuncture
X-Rays
Hydrotherapy
–
Medical Exams
Ultrasound
Physical Therapy
Laser Therapy
–
Pet Health Centers Member Program
Referral Program
Pet Health Insurance
New Clients
Pet Health
Library
Pet Health Checker
Pet Portal
News
Online Pharmacy
New Clients
New Client Information Form
Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.
Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a blue * asterisk.
Owner's Information
Name
*
First
Last
Address
*
Street Address
Apt/P.O. #
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Home Telephone Number
*
Mobile Number
*
Email
*
Enter Email
Confirm Email
Pet Information
Pet's Name
*
Species
*
Dog
Cat
Sex
*
Male
Female
Is your pet Spayed/Neutered?
*
Yes
No
Breed (if known)
Date of Birth or Age (if known)
Color
Does your pet have a microchip?
*
Yes
No
If so what is the microchip number:
Was your pet rescued from a shelter or rescue group?
*
Yes
No
Was your pet adopted from North Shore Animal League America?
*
Yes
No
If so what is the adoption number:
Other Related Information
How did you find out about our practice?
Google Search
Newspaper
NSALA Adoption Center
Website
Referral
What is the full name of the referee?
Please read and agree:
Thank you for choosing North Shore Animal League Pet Health Center as your veterinary health care provider. We are dedicated to providing the highest quality health care to all of our patients. In order to assist in an increasing number of patients, and to keep our services at affordable costs while providing the highest quality of care, we cannot extend credit. Please understand that payment is due at the time of services rendered. We may also require a deposit for major procedures. The following payment options are accepted:
*Cash or personal check with valid state license/ID. Checks are electronically processed the same day. WE DO NOT ACCEPT POST DATED CHECKS
*Bank credit or debit card. We accept payment from all major credit cards
Policy Agreement
*
By submitting this form, I have read, understand, and agree to the above financial policy.
About
Services
–
Medical
Wellness
Surgical
Dental
Vaccinations
Orthopedic
–
Spay/Neuter
Microchipping
Blood Tests
Acupuncture
X-Rays
Hydrotherapy
–
Medical Exams
Ultrasound
Physical Therapy
Laser Therapy
–
Pet Health Centers Member Program
Referral Program
Pet Health Insurance
New Clients
Pet Health
Library
Pet Health Checker
Pet Portal
News
Online Pharmacy