Briar Patch Veterinary Hospital
706 Elmira Road
Ithaca, NY 14850
(607)272-2828
fax (607) 272-2875


Welcome to Our Site

New Client Information

The following information will allow us to expedite your check in.

Form - New Client or Pet

Have you brought pets to us before?
yes
no

If no, how did you hear of us?
internet
newspaper, yellow pages or radio ad
referred by a friend or family member

Primary Owner's Name (required)
First Name (required)
Last Name (required)
Co-Owner's Name
First Name
Last Name
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Primary Owner's Daytime Phone (required)
Phone TypePhone Number (required)
Co-Owner's Daytime Phone
Phone TypePhone Number
Home Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (please list each pet on a separate form) (required)

Date of Birth or Approximate Age:

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current?
Is your pet currently on any medications or special diet?

Do you have any previous medical records for your pet?
Name of previous vet hospital?

May we request a transfer of records? (If yes, please complete Records Transfer Form also)
Yes
No

Previous vet's phone number?


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