CANINE REHAB OF NEW YORK WELCOMES NEW CLIENTS

Thank you for considering CANINE REHAB OF NEW YORK for your pet’s rehabilitation care needs. We welcome the opportunity to help you provide your dog or cat with the best available rehabilitation care. To schedule your pet’s initial appointment please call us at 212.222.0010 or use the form below. We look forward to helping your pets’ mobility.

PAYMENT OPTIONS

We accept the following forms of payment: cash, personal check, VISA, MasterCard, American Express, Discover, PaymentBanc, and CareCredit. To expedite payment at future visits you may submit a Credit Card Authorization Form.

ONLINE REGISTRATION

To inquire about rehabilitation for your dog please use the online form below. We will contact you within 24 hours to discuss your pet’s condition and how we may be able to help. Please send previous medical records to info@caninerehabofny.com

YOUR INFORMATION

* = required field

First Name: *

Last Name: *

Address: *

Apartment:

City: *

State: *

Zip Code: *

Mobile Phone: *

Home Phone:

Work Phone:

E-Mail: *


 

PARTNER INFORMATION

Spouse/Partner First Name:

Spouse/Partner Last Name:

Spouse/Partner Mobile Phone:

E-Mail:


 

EMERGENCY CONTACT

First Name: *

Last Name: *

Relationship: *

Mobile Phone: *

E-Mail: *


 

PET INFORMATION

Pet Name: *

Date of Birth: *

Gender: *

Species: *

Breed: *

Neutered/Spayed: *

Color/Markings: *

Food Allergies: *

Why Are You Seeking Pet Rehabilitation?: *


 

ADDITIONAL INFORMATION

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I agree to Terms & Conditions. By checking here I agree to pay all charges incurred at time services are rendered. *
Check here if you accept these terms.

Photo Consent: We love social media! Do we have your permission to share your pet(s) image and story on social media, our website and other forms of related media? Your name and personal information will never be shared. *


 

SUBMISSION CONFIRMATION

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