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Hours 140 W 67th St
New York, NY 10023

Medically Supervised Stay Information Form

Thank you for working with the compassionate veterinary professionals at Lincoln Square Veterinary Hospital! Please complete the required form below before your pet's visit. For immediate assistance, please call our office: (212) 712-9600

Pet Information

Pet's Name*

Breed*

Color*

Age / Birthdate*

Gender*

Female

Spayed Female

Male

Neutered Male

Owner Contact Information

Are you leaving NYC?*

Yes

No

Where can you be reached?*

Please list your emergency contact's name and phone number:*

When will you pick up your pet?*

Would you like any additional services while your pet is in our care? (Additional fees may apply)

Medications

Does your pet have any medical conditions or allergies?

Is your pet on any medications and if so, how often?

Please list all medications and when they were last given:

How often do you feed your pet? How much?

Brand of Dry Food

Brand of Canned Food

WE FEED HILLS I/D TO ALL PETS IN THE HOSPITAL UNLESS YOU PROVIDE YOUR OWN PETS DIET*

I understand

Lincoln Square Veterinary Hospital