Register a pet with Our House Call Vet to make an appointment

OUR HOUSE CALL VET Bergen NJ, Passaic NJ & Rockland NY

Registration Form

* Indicates required field

Name *

First

Last

What search word did you use? Or who referred you? *

Address *

Line 1

Line 2

City

State

Zip Code

Country

If you live in an apartment/ condo/etc, please give us the building number and advise us on where to park. *

Home Phone Number - INCLUDE DASHES *

Please include dashes between area code, prefix of phone number.

Cell Phone Number - INCLUDE DASHES between area code, prefix and suffix *

Please put dashes between the area code, prefix and suffix of the phone number.

Email *

Pet's Name *

Choose One Please *

Dog Cat

If you have a cat, is it declawed? *

Sex *

Male Female I don't know

Is your pet spayed or neutered? *

Yes No I don't know

Is your pet microchipped *

Yes No I don't know

Pet's Birthdate *

Breed *

Color *

Weight - please approximate if you do not know *

Date of Last Rabies Vaccination *

List ALL other vaccinations, AND the month/year they were given (ex.DHPP 4/2017, Bordetella 4/2017, Lyme 4/2017, FVRCP 3/2016, Felv 3/2016, etc) *

List the vaccination name AND the date that it was last given.

Brief reason for visit *

Has your pet ever bitten, growled,or scratched at anyone (including a Veterinarian)? Feel free to explain the circumstances. *

This is very important, as it will determine which technician we need to take with us.

I agree to pay in full, with cash or a check, for services at the time services are rendered. *

Yes No

Submit