New Patient Form

Primary Contact

Owner Name (First and Last)

Phone Number

Email Address

Additional Phone Number (If applicable)

Home Address (Please include apartment or floor number if applicable)

City, State, Zip Code

Secondary Contact

First and Last Name, Relationship (E.G. John Brown, Spouse)

Phone Number

Email Address

Please list the name and phone number of anyone else authorized to make medical decisions for your pet.

Patient Information

Pet’s Full Name (First and Last)

Date of Birth (Or estimated age)

Species

Breed (Please write N/A if unsure)

Gender

Color

Spayed/Neutered?

Has your pet been seen by any of the cardiologists listed below?

Reason for visit (e.g. heart murmur, arrhythmia, enlarged heart, recheck visit, pre-anesthesia clearance, etc.)

Primary veterinarian & name of veterinary practice (please write N/A if your pet does not see a regular vet)

Referring veterinary practice & address (if different than regular vet)

Has your pet been seen by any other cardiologist outside of The Animal Cardiology Center?

If your pet has been seen through an emergency room or by any other veterinary specialists (e.g. ophthalmologist, dermatologist, cardiologist, etc.), please list the names of the practice(s) here.

Please list any pertinent medical history/diagnoses (e.g. diabetes, asthma, blindness, etc.) for your pet here.

Please list all medications your pet is currently taking. medication name, strength, frequency (e.g. Furosemide, 20mg tablets, give 1 tablet by mouth twice daily).

Please list any supplements your pet receives routinely (e.g. fish oils, joint supplements, taurine. Please include brand name).

Is your pet on heartworm prevention?

If yes, please list the brand of the preventative they receive.

What diet does your pet eat? Please include the name of the brand.

Is your pet's food grain free?

Preferred local pharmacy (name & phone number)

Preferred compounding pharmacy (if applicable)

How did you hear about us? (e.g. Google search, referral, friend, Yelp, VERG patient, etc.)

Agreement

Online Scheduling Policy Acknowledgement: You will be contacted in the next business day to provide a non-refundable deposit to confirm your appointment. If we are unable to reach you within 48 hours of scheduling, your appointment will be cancelled. Additionally, if you need to reschedule or cancel this appointment, please phone us at (212) 722-0449 to assist you at least 24 business hours prior to your scheduled appointment time.

I have read, fully understand, and agree to the terms and conditions stated above.

Payment Policy: We accept all major credit cards and Care Credit. A physical form of payment is required at the time services are rendered.

I have read, fully understand, and agree to the terms and conditions stated above.

By typing your name below, you agree to the following: I hereby authorize the veterinarian/staff of The Animal Cardiology Center to examine, treat, and prescribe medications for the above described pet. I understand that all patients must be vaccinated for rabies. I assume financial responsibility for all charges incurred in the care of the animal. I also understand that payment is due in full at the time services are rendered. Medical photographs may be taken during your visit. These images will be used for disease monitoring; however, they may also be used for educational as well as social media and marketing purposes. Your information and pet’s name will not be associated with these images.

Thank you!

Our team will be reaching out to you shortly. In the meantime if you have questions, please reach out to info@taccvets.com!

Oops! Something went wrong while submitting the form.