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Client/Patient Information Form

Name: Greece Animal Hospital
Address: 3180 Latta Rd, #800, Rochester, NY, 14612, United States
Telephone: 585-227-7100
Price range: $

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Client/Patient Information Form

Please complete our Client/Patient Form. All fields marked with * are required and must be filled.

Owner's Name *

First

Last

Co-Owner's Name

First

Last

Primary Phone *

Secondary Phone

Email *

Co-Owner's Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How would you prefer we contact you?

Email
Phone

Best number to contact you *

The following individual(s) is designated as alternate to give consent for services in my absence. The designation remains in place until the hospital is otherwise notified. As the owner, you are still responsible for any charges incurred by the consent given by the alternate individual.

Name

First

Last

Phone

Have you been to a veterinarian before?

Yes
No

If yes, who?

How did you become aware of our hospital? *

If other, please specify *

NOTE: For the safety of all animals here, it is our policy that all animals be up to date with their vaccinations in order to be hospitalized or boarded.

Patient 1:

Pet Name *

Species *

Breed *

Color *

Sex *

Male
Female

Spayed/Neutered? *

Yes
No
Unsure

DOB or Approximate Age *

Add another pet? *

Yes
No

Patient 2:

Pet Name *

Species *

Breed *

Color *

Sex *

Male
Female

Spayed/Neutered? *

Yes
No
Unsure

DOB or Approximate Age *

Add another pet? *

Yes
No

Patient 3:

Pet Name *

Species *

Breed *

Color *

Sex *

Male
Female

Spayed/Neutered? *

Yes
No
Unsure

DOB or Approximate Age *

Add another pet? *

Yes
No

Patient 4:

Pet Name *

Species *

Breed *

Color *

Sex *

Male
Female

Spayed/Neutered? *

Yes
No
Unsure

DOB or Approximate Age *

I, the undersigned, am at least 18 years of age and hereby state that I am the owner/caregiver of the above-specified animals.

I hereby give consent for the use of any images of my pet, taken by Greece Animal Hospital, in any and all marketing materials, including, but not limited to: the website, social media accounts and digital/print promotional materials. *

Yes
No

In the event that payment is not received and my account is placed for collection, I agree to pay service charges in the amount of 1.5% per month (18% per annum) in addition to the amount.

Upload Medical Records

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

Signature *

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Your preferred Rochester veterinary hospital.

Our veterinarians and staff have a long tradition of community service. Animals, medicine and science are our passions and we are devoted to treating every animal and owner as a trusted friend. We serve the communities of Rochester and the surrounding area.

Contact

P: 585-227-7100
F: 585-227-5087
E: info@greeceanimalhospital.com

Hours

Mon - Thurs: 8 am - 6 pm
Fri: 8 am - 5 pm
Saturdays: Please call for hours

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Location

3180 Latta Rd, #800
Rochester, NY 14612

DOWNLOAD APP

Ready to begin earning rewards?

Click the buttons below to download our app from the App Store or Google Play.
Click the “Log in” button on the right-hand corner to create your account.
Use the email address on file with us and a password of your choice.
You will then receive a confirmation email to verify your account.
Open the email and click the “Verify your email address” button.
You will automatically receive your first loyalty stamp once your email has been verified.
Your pet information will sync with our system and show up in the app the next day.

Have questions about our app? Call us for more information!

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