New Patient Registration - Colorado Springs - Centennial Animal Hospital

Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Which number is best to reach you? *

Home
Cell

Can you receive text messages? *

Yes
No

Email *

Add a co-owner? *

Yes
No

Name *

First

Last

Home Phone

Cell Phone

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 *

Sex *

Male
Female

Neutered/Spayed? *

Yes
No

Breed *

Color *

Birthdate or Age *

Current Medications

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

DIET AND ENVIRONMENT

What food does patient currently eat? *

Amount and frequency? *

Is your pet on any dietary supplements? *

Yes
No

If so, what kind and what dosage? *

Does your pet consume table food? *

Yes
No

If 'Yes', please explain: *

Is your pet primarily indoor or outdoor? *

Indoor
Outdoor

Are there any other animals in the household? *

Yes
No

If 'Yes', please describe: *

Do you have your pet groomed or boarded outside of your home? *

Yes
No

If so, how often? *

Do you travel outside of Colorado with your pet? *

Yes
No

If you do travel out of the state with your pet, where do you travel to? *

PAST HISTORY

Has your pet had any prior illnesses, accidents, or surgeries? *

Yes
No

If 'Yes', please explain:

Is your pet aggressive or fearful around strangers? *

Yes
No

If 'Yes', please explain: *

Is your pet on heartworm, flea/tick preventatives? *

Yes
No

How frequently do you give your pet flea/tick preventatives? *

Year-Round
Seasonally

Please list any other medications or supplements your pet receives below:

Does your pet have any known allergies to any medications? *

Yes
No

If 'Yes', please list: *

Has your pet ever had a reaction to any vaccines? *

Yes
No

If 'Yes', please list and explain: *

OFFICE POLICIES

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, 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 order 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 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. *

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. *

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. *

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? *

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). *

I have read and agree.

Emergency Contact *

First

Last

Emergency Contact Phone *

Owner's Signature *

Date *

File Upload

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New Patient Registration Form

New Patient Registration Form

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