Rockland Animal Hospital

355 Old County Road
Rockland, ME 04841

(207)594-5850

www.rocklandanimalhospital.com

New Client Check-In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooperation in letting us assist you.

New Client

Name *(required)*

First Name (required)	Last Name (required)

Street Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Home Phone (required)
Phone Type	Phone Number (required)

Work Phone (required)
Phone Type	Phone Number (required)

E-Mail Address (required) :

Employer and their address:

Who may we thank for recommending our hospital to you?

Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :

Breed: (required)

Sex: (required)

Male
Female

Neutered/Spayed (required)

Neutered
Spayed

Are your pet's vaccines current?

Do you have your pet's medical records?

Medical records at another veterinary Practice?

Yes
No

Name and phone number of Former Veterinary Practice (Please call them and have them send records)

Would you like us to call you to set up an appointment? (required)

Yes
No

Reasons or conditions that prompted your visit?

Please list any additional pets here

Hours of Operation:
The Rockland Animal Hospital is staffed during normal operating hours which are Monday - Friday 7:30 am to 5:30 pm and Saturdays 8:00 am to 12:00 noon. On the weekends and holidays a staff member cares for pets boarding with us. After hours emergencies are covered by the Midcoast Animal Emergency Clinic, 191 Camden Road in Warren, Maine, Telephone: 273-1100.

Payment Policy:
All fees are due upon release of a patient. We charge 1.5% interest on any balance over 30 days. There is a $5.00 billing charge per statement. If payment on an account becomes delinquent you agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of 33% of the debt and all costs and expenses, including reasonable attorneys fees, we incur in such collection efforts.

I have read and agree with the payment policy outlined above. (required)

Yes

Indicate your choice of payment:

Cash/Check
Visa/MasterCard
Care Credit
American Express
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