Please fill out our New Patient Form using one of the options below if your dog or cat is a new patient at Van Roekel & Associates.

Option 1

Complete Online

Complete and submit the online form below.

Option 2

Complete on Arrival

If you prefer, fill out the form when you get to our hospital.

New Dog or Cat Form

Owner Information

Owner First Name *

Owner Last Name *

Secondary Owner / Authorized Agent Name

Email *

Primary Phone *

Mobile Phone

Work Phone

Address *

City *

State *

Zip Code *

Employer *

Occupation *

Date of Birth *

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

Patient Information

Pet Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Vaccination Status *

Gender *

Spayed or Neutered? *

Presenting problem, special needs, concerns *

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 Van Roekel & Associates to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

By submitting this form, I hereby authorize Van Roekel & Associates 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 Van Roekel & Associates.

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Patients

Patients
New Dog or Cat Form
New Horse Form
Pet Care Tips
Financing Options

Pet Records Sign-in Appointment Requests Refill Requests Equine Emergencies Cat & Dog Emergencies

Happy Tails From Clients

My puppy needed emergency surgery to remove a foreign body from her stomach. The vet not only exceeded all expectations with the procedure but post-operative care as well. I was contacted daily with updates and the vet was readily available for any questions I had. When I picked Coco up to come home, they made sure I was comfortable with her care going home and they have remained in contact with me daily to check on Coco. Van Roekel is one of a kind, I recommend them to anyone looking for a family feel veterinarian, that will love your pet like it’s their own.
- Amanda

New Patients Welcome

We are accepting new patients at Van Roekel & Associates! Our veterinary team is dedicated to the care of North Fort Myers dogs and cats, horses, and farm animals. Reach out today to book your animal's first appointment.

New Patient Form for Dogs & Cats

Option 1

Complete Online

Option 2

Complete on Arrival

New Dog or Cat Form

Owner Information

Emergency Contact

Patient Information

Primary Veterinarian Information

New Patients Welcome