Email
Chelsea
Lower East Side
Hell’s Kitchen
Facebook
Instagram
Twitter
YouTube

Home
About
Services
Client Services
Contact
Appointment
Online Pharmacy

Select Page

Upload Records

Upload your pet’s records before your visit.

Hospital Location *

Chelsea
Lower East Side
Hell's Kitchen

Name *

First

Last

Phone *

Email *

Pet's Name *

Are you an existing client? *

Yes
No

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Spouse/Co-Owner Name

First

Last

Spouse/Co-Owner Phone

Preferred Contact Method *

Phone
Email

How did you hear about us? *

Google
Facebook
Yelp
Sign/walked by
Referral
Other

Who referred you, we'd love to thank them! *

If other, please explain *

Patient Information

Pet's Name *

Species *

Dog
Cat
Other

If other, please elaborate *

Age

Date of Birth

Sex *

Female
Spayed female
Male
Neutered male

Breed *

Color

List any known allergies

Other pets in the household? *

Yes
No

Would you like to add information for another pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat
Other

If other, please elaborate *

Age

Date of Birth

Sex *

Female
Spayed female
Male
Neutered male

Breed *

Color

List any known allergies

Would you like to add information for another pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat
Other

If other, please elaborate *

Age

Date of Birth

Sex *

Female
Spayed female
Male
Neutered male

Breed *

Color

List any known allergies

Do you have pet insurance? *

Yes
No

If yes, please let us know which company

Policy #

Former Veterinarian Name/Hospital

Former Veterinarian's Phone Number

Have you booked your appointment? *

Yes
No

Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment or hospital treatment. *

I have read and agree

I hereby authorize the release of my pet’s medical records to another facility (boarding/daycare, insurance company, urgent care facility, etc.), should they be requested. *

Yes
No

Signature *

Date *

Please upload any medical records for your pet. *

Click or drag files to this area to upload. You can upload up to 10 files.

Any additional comments?

Email

We have three locations for your convenience!

Chelsea

257 West 18th Street
New York, New York 10011

Phone: (212) 924-6116

Lower East Side

241 Eldridge Street
New York, New York 10002

Phone: (212) 390-VETS (8387)

Hell's Kitchen

453 West 46th Street
New York, New York 10036

Phone: (212) 433-3420

Book an appointment online!

Book your next appointment online in just a few minutes. We can't wait to see you!

LOWER EAST SIDE

CHELSEA

Facebook
Twitter
Instagram

©2021 Heart of Chelsea Veterinary Group | Powered by WhiskerCloud