Clone of Current Client Appointment Request form

Emergency Appointment Request form

Please text us first to make sure we are available for the appointment day/time needed. (Holiday and Weekends) Please be advised this is for emergencies that can be managed in a house-call setting.
Client Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Phone number above is*

Cell PhoneHouse phone
Preferred method of communication*

TextEmailPhone
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please choose the date you are requesting

MonthDayYear
Pet's name(s) : *
Is this a new pet we have not seen before?*

Pet Information (If we have not seen them before)

	First Pet	Second Pet	Third Pet
Pet's Name
Species
Breed
Color
Birthdate or approximate age
Sex
Fixed? Y/N
Weight (approximate)

Reason for visit:*
I understand that the house call Emergency fee minimum is $365. Any diagnostics, treatment and/or medication will be at an additional charge and the the full amount will be due at the time the services are performed and medications are dispensed. If you must change or cancel your appointment, 24 hour notice must be given. For all visits there is a $50 fee for change or cancellation within 24 hours of your appointment time, $200 fee within 12 hours of appointment time, and $365 fee when Dr. Alana is already driving to your home or there is no answer at your door.You give permision for Dr. Alana Lauritano to handle, exam, and treat your pet.
Signature

Clear

Authorize the card now to charge it manually later. Expires after 6 days. Your card will NOT be charged until your appointment is confirmed. *

House call emergency visit (Holiday or weekend) Central Suffolk

$365.00

House call emergency visit (Holiday or Weekend)west of Route 110 or east of Riverhead)

$415.00 Quantity

Total

$0.00

Emergency Appointment Request form