Admissions

Name: Veterinary Specialists and Emergency Services
Address: 825 White Spruce Blvd., Rochester, NY, 14623, United States
Telephone: 585-424-1277
Price range: $

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Admissions Form

Please follow the below steps:

1. Call 585-424-1277 to alert us of your emergency.
2. Complete the Admission Form below prior to your arrival.

Owner Information

Client's Name*

Prefix First Last

Co-Owner's Name

Prefix First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone:

Work Phone:

Cell Phone:

Co-Owner's Phone:

Email Address:*

Preferred Contact Number:*

Pet Information

Pet Name*

Species*

Pet Breed*

Coat Color*

Sex*

Female

Male

Spayed/Neutered*

Yes

Birthday or Approximate Age*

Medical Alert

(Medications/Chronic Condition/Allergies)

Pet's Veterinarian Name/Hospital*

(Place N/A if you do not have one)

I authorize Veterinary Specialists and Emergency Services to release my pet’s medical information to the veterinarian(s)/ hospital(s) named above or any hospital where I may choose to receive follow up care for my pet.

I agree.

Medication pet is currently receiving:

Other

I am at least 18 years of age and I accept financial responsibility for all charges incurred for medical services my pet receives. Should a doctor recommend hospitalization for surgery or other treatment, I will be presented with an estimate for charges that may be incurred during hospitalization. A monetary deposit that equals half of the high end of the presented estimate will be required. ALL FEES ARE REQUIRED TO BE PAID IN FULL UPON COMPLETION OF THE VISIT. In the event any balance due hereunder is not paid as agreed, the undersigned jointly and severally agree to pay all costs included in said unpaid balance, including a reasonable collection and/or attorney's fees.

Signature*

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Admissions

Admissions Form

Contact

Hours

Location

Continuing Education