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 Vet:

Previous Vet's Phone Number

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 foot does patient currently eat? *

Amount & 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

Please explain *

Is your pet primarily indoor or outdoor? *

Indoor
Outdoor

Are there any other animals in the household? *

Yes
No

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 so, where? *

PAST HISTORY

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

Yes
No

Please explain.

Is your pet aggressive or fearful around strangers? *

Yes
No

Please explain. *

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

Yes
No

How frequently? *

Year-Round
Seasonally

Please list any other medications or supplements your pet receives.

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

I have read and agree.

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 *

Digital Signature of Owner *

Date *

New Patient Registration Form

New Patient Registration Form

Address

Hours

Contact

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