Medical Concern Illness/Injury Appointment Form

Centennial Animal Hospital Medical Concern Illness/Injury Appointment Form

Thank you for entrusting your pet’s care to us! The following information will be used to help our veterinary team accurately complete your pet’s medical history for today’s visit. We will need to be able to contact you or someone with permission to make medical and financial decisions.

The check-in for all visits will occur over the phone, so please provide the information below even if you intend to attend your pet’s appointment.

Date of Appointment(Required)

MM slash DD slash YYYY

Time of Appointment(Required)

Hours

Minutes

AM/PM

Name(Required)

First Last

Email(Required)

Phone(Required)

Pet's Name(Required)

Species(Required)

Dog

Cat

Other

If other, please specify(Required)

Who should we contact to make medical decisions today?(Required)

Myself

Someone else

Name(Required)

First Last

Phone(Required)

Should we call as you wait in your vehicle for a curbside visit, or would you prefer to be present in the exam room?(Required)

In-person visit

Call

Reason for visit (check all that apply):(Required)

Illness

Injury

Other

If other, please specify(Required)

What symptoms has your pet been experiencing?(Required)

Have you noticed any issues/problems with your pet? Are there any concerns for the following (check all that apply):(Required)

Increase in appetite

Decrease in appetite

Increase in drinking

Decrease in drinking

Weight loss

Weight gain

Itching/scratching

Shaking head

Bad breath

Vomiting

Diarrhea

Urination issues

Excessive sleeping

Scooting

Difficulty rising

Skin masses

Car sickness

Behavioral problems

Other

None of the above

If other, please specify(Required)

When did the problem start?(Required)

Have the symptoms worsened, improved, or stayed the same since you first noticed them?(Required)

Worsened

Improved

No change

Has your pet experienced this problem in the past?(Required)

Yes

Is your pet on any medications?(Required)

Yes

If yes, please list medication name, dosage, and frequency(Required)

What brand and type of food do you feed your pet?(Required)

How much do you feed?(Required)

Free fed (food is offered always/whenever hungry)

Measured amount (specify how much and how often below)

How much and how often do you feed your pet?(Required)

Have there been any changes in appetite?(Required)

Increased

Decreased

No change

If there has, for how long? Please elaborate.(Required)

Any increase or decrease in water consumption?(Required)

Increased

Decreased

No change

Any change in bowel movements?(Required)

Yes

Unsure

Does your pet spend time outside, even for walks or in the yard?(Required)

Yes

Does your pet come into contact with other dogs? Please check all that apply(Required)

None

Boarding

Grooming

Dog parks

Other

If other, please specify(Required)

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure?(Required)

Yes

If yes, please explain(Required)

Was your pet last seen by a veterinarian at Centennial Animal Hospital?(Required)

Yes

Name of Previous Veterinarian(Required)

Many of our patients enjoy treats while visiting our office, but if your pet has an allergy, please let us know no treats or bring approved treats. Can your pet have treats (low fat I/D kibbles, or cheese)?(Required)

Yes

Once the doctor has completed your pet’s exam if curbside, we will contact you to go over the recommended treatment plan. I understand that financial responsibilities for services are rendered at the time of discharge.(Required)

I have read and understand

To allow for ample time for all patients, CAH runs primarily by appointments. We request all clients to be on time for their scheduled appointments. If you are 15 minutes late to your appointment you may be asked to reschedule your appointment. If you have multiple concerns for your pet, please let us know when scheduling. Cancellation policy for appointments please give us 24-hour notice so we can accommodate getting another patient in to be seen.

You can expect most wellness and vaccine appointments to last about an hour from check in to check out. Sick and Urgent care appointments may require diagnostics which can take additional time. They can take (1-3 hours) from check in – check out.(Required)

I have read and understand.

For your protection, and that of others, all pets should be properly restrained by a leash or carrier. If your pet requires special accommodation, please let us know when you arrive. We do ask that you still check in from the parking lot and we will bring you inside as soon as we have a room available.(Required)

I have read and understand.

THE VETERINARIAN-CLIENT-PATIENT RELATIONSHIP (VCPR) is the basis for veterinary care and is critical to the health of your animal. This requires mutual trust and respect for us to provide the highest quality of care for your pets. We have a zero-tolerance policy for abusive, aggressive, bullying, or combative behavior. Should this behavior be directed toward any of our staff in person or on the phone we will terminate our VCPR with you immediately and you will need to find veterinary services elsewhere. If you have any questions or concerns about the treatments being recommended or the services provided, please let us know right away.(Required)

I have read and understand.

I certify that I am 18 years of age or older and responsible for the financial and medical decisions for the above-mentioned pet. If you send someone else in your place, they must be 18 years of age or older and you are authorizing them to act on your behalf. You are still financially responsible for all charges incurred for the care of this pet. I understand that payment is ALWAYS DUE IN FULL at time of service. We are happy to provide estimates for any recommended services, just let us know on arrival. A 50% deposit of the treatment plan may be required before treatments or hospitalization of your pet are rendered. I understand that any financial concerns should be discussed PRIOR to the examination and treatment consent. We accept cash, debit, or all credit cards. We also offer Care Credit or Scratch Pay.(Required)

I certify.

Signature(Required)

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We treat your pets like the valued family members they are.

Address

6870 Centennial Blvd.
Colorado Springs, CO 80919
Click here for directions.

Hours

Mon – Fri: 8:00 am – 6:00 pm
Sat: 8:00 am – 12:00 pm
Sun: Closed

Contact

Phone: 719-528-1693
Fax: 719-528-1694
Email: centennialpets@gmail.com

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