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Patient Registation Form

Before your pet's first visit to LIBEVC, please fill out the our Patient Registration Form using one of the options below. This will help save time on the day of your appointment. If you're already registered with us, please call  (516) 482-1101 to schedule an appointment.

Option 1

Complete Online

Complete and submit the online form below.

Option 2

Print & Complete

Bring the completed form with you to our clinic.

Option 3

Complete on Arrival

If you prefer, fill out the form when you arrive at the clinic.

New Patient Registration Form

Owner Information

Emergency Contact

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable?
Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians?

Patient Information

Primary Veterinarian Information

Please fill this section in if we are not your primary care veterinary hospital. By listing your primary care veterinarian, you are authorizing LIBEVC to release patient information to the primary care hospital or veterinarian.


By submitting this form, I hereby authorize LIBEVC to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from LIBEVC.


Please note that this $105.04 deposit is non-refundable if an appointment is scheduled and you do not show or cancel the day of. It will be credited towards your first exam fee. Once your payment is processed through our website, one of our staff members will contact you within the business day (which may be the following morning if you complete this form overnight) to help you choose between our available appointment days and times. If we do not contact you within that time frame, please call us at 516-482-1101 or email us at; this will also help us to confirm that the online registration process worked correctly. The fee is to only cover the cost of the physical examination, any treatments discussed with the doctor will be additional costs due at the time of the exam. Thank you.

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