New Patient Registration Form

Thank you for giving Centennial Animal Hospital the opportunity to care for your
pet(s). To ensure the best care possible, please fill out this form completely.

Please bring proof of vaccination. If you were unable to submit them prior to your appointment, please arrive 15 minutes early.

Owner's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Which number is best to reach you?(Required)

Home

Cell

Can you receive text messages?(Required)

Yes

No

Email(Required)

Add a co-owner?(Required)

Yes

No

Hidden

Co-Owner

Co-Owner's Name(Required)

First Last

Home Phone

Cell Phone

Which number is best to reach you?(Required)

Home

Cell

Can you receive text messages?(Required)

Yes

No

Email(Required)

Hidden

Section Break

Previous Veterinarian

Previous Veterinarian's Phone Number

City and State of Previous Veterinarian

Whom should we thank for referring you?

PET HEALTH HISTORY

Pet's Name(Required)

Sex(Required)

Male

Female

Spayed/Neutered?(Required)

Yes

No

Breed(Required)

Color(Required)

Age/Date of Birth(Required)

Current Medications

Please bring and give any medical records/vaccine records to the receptionists to make copies.

DIET & ENVIRONMENT

What food does patient currently eat?(Required)

Amount and frequency?(Required)

Is your pet on any dietary supplements?(Required)

Yes

No

If so, what kind and what dosage?(Required)

Does your pet consume table food?(Required)

Yes

No

If yes, please explain(Required)

Is your pet primarily indoor or outdoor?(Required)

Indoor

Outdoor

Are there any other animals in the household?(Required)

Yes

No

If yes, please describe(Required)

Do you have your pet groomed or boarded outside of your home?(Required)

Yes

No

If yes, how often?(Required)

Do you travel outside of Colorado with your pet?(Required)

Yes

No

If you do travel out of the state with your pet, where do you travel to?(Required)

PAST HISTORY

Has your pet had any prior illnesses, accidents, or surgeries?(Required)

Yes

No

If yes, please explain(Required)

Is your pet aggressive or fearful around strangers?(Required)

Yes

No

If yes, please explain(Required)

Is your pet on heartworm, flea/tick preventatives?(Required)

Yes

No

How frequently do you give your pet flea/tick preventatives?(Required)

Seasonally

Year-round

Please list any other medications or supplements your pet receives below

Does your pet have any known allergies to any medications?(Required)

Yes

No

If yes, please list(Required)

Has your pet ever had a reaction to any vaccines?(Required)

Yes

No

If yes, please explain(Required)

APPOINTMENT DEPOSIT & CANCELLATION POLICY

A $65.00 non-refundable deposit for all appointments at the time of scheduling to confirm and hold your appointment. The deposit will be applied to your balance due at the end of your appointment. We ask for at least 24 hours' notice, as a courtesy, if you will need to cancel or reschedule your appointment. If you cancel or reschedule less than 24 hours prior to your appointment time your deposit in non-refundable, and a new deposit will be required to book a future appointment.(Required)

Initial

OFFICE POLICIES

Office Policies(Required)

To allow for ample time for all patients and surgical procedures, Centennial Animal Hospital operates primarily by appointment. We request all our clients be on time for scheduled appointments and procedures. If you are 15 minutes late to your appointment, you may be asked to reschedule your appointment. We do take Emergencies; however, these services may be subject to a higher fee schedule. For your convenience, we offer limited same-day appointments for urgent care and sick patients. They fill up fast, so we recommend calling first thing in the morning.

For your protection and that of others, pets should be properly restrained by a leash or carrier upon arrival. If your pet requires special accommodations, please give us a call when you arrive so we can assist you and your pet.

If you must cancel an appointment, we ask for 24 hours’ notice. For surgical appointments, we ask for a 48-hour cancellation notice.

We accept cash, debit, or all credit cards. We also offer Care Credit or Scratch Pay financing to help make the highest quality care accessible to all our patients.

We would be more than happy to fill your prescriptions or have your food orders ready for pick-up. Please call ahead or use our website to process refills. Please allow 24-48 hours for prescription refills; special orders or controlled substances may require longer. We do not authorize online pharmacy requests by phone or fax. If you need a written prescription to be processed at the pharmacy of your choosing, you will need to pick them up in person.

I have read and agree

I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet. I assume responsibility for all charges incurred in the care of this animal.(Required)

I have read and agree

I understand that Centennial Animal Hospital does not have staff on premises after hours, and we do not offer after-hour emergency care. Should you have an after-hours emergency, please visit Animal ER Care located at 5520 N Nevada Ave #150, Colorado Springs, CO 80918. They are open 24/7, and their phone number is 719-260-7141.(Required)

I have read and agree

I understand that payment is ALWAYS DUE IN FULL at the time of service. A deposit of 50% of the treatment plan may be required before the treatment or hospitalization of your pet. I recognize that financial concerns should be discussed PRIOR to examination and treatment.(Required)

I have read and agree

We would like to feature your pet on our Facebooks Fantastic Friday Faces! Do we have your permission to share your pet’s image and story on our social media, website, and other forms of related media?(Required)

Yes

No

I authorize my emergency contact (other than myself) to pursue treatment if I am unavailable (your emergency contact must be an adult over the age of 18).(Required)

I have read and agree

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Signature(Required)

Date(Required)

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