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.

*Important Update Beginning January 15, an $8.00 fee will be applied to all tech appointments. This change helps us support our skilled staff and maintain the high level of care your pets deserve. Toenail trims are excluded at this time. Thank you for your understanding and continued support.

X/Twitter

This field is for validation purposes and should be left unchanged.

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

Email(Required)

Add a co-owner?(Required)

Yes

This field is hidden when viewing the form

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

Email(Required)

This field is hidden when viewing the form

Section Break

Previous Veterinarian (If you do not have one please put n/a).(Required)

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

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

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

Does your pet consume table food?(Required)

Yes

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

If yes, please describe(Required)

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

Yes

If yes, how often?(Required)

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

Yes

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

If yes, please explain(Required)

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

Yes

If yes, please explain(Required)

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

Yes

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

If yes, please list(Required)

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

Yes

If yes, please explain(Required)

APPOINTMENT SCHEDULING FEE & CANCELLATION POLICY

A $80.00 non-refundable scheduling fee for all appointments at the time of scheduling to confirm and hold your appointment. The scheduling fee 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 scheduling fee in non-refundable, and a new scheduling fee will be required to book a future appointment.(Required)

Initial

OFFICE POLICIES

Office Policies(Required)

To allow for ample time for all patients & surgical procedures, CAH runs primarily by appointments. We request all clients to be on time for their scheduled appointments and procedures. If you are 15 minutes late to your appointment you may be asked to reschedule your appointment. We will also do our best to keep on schedule, barring any emergencies.

We offer limited same day urgent care appointments that can fill up fast! If your pet is sick call us first thing in the morning or as soon as you note they are sick, so we can do our best to accommodate getting your pet in right away.

Please call ahead with any emergencies. Emergencies are subject to the availability of our doctors and staff. By calling ahead we can be prepared to receive your pet or direct you to the nearest ER should that be in your pet’s best medical interest.

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.

For prescription medications and food please call ahead or use our website to process your refill requests. Please allow 24-48 hours for prescription refills. Special order and controlled substances may take 3-5 days or longer. We do not authorize or work with online pharmacies. We will provide a written prescription on request that you can use at the pharmacy of your choosing, and you will need to pick up the written prescriptions in person.

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.

I have read and agree

I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet(s). 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 time of service. A 50% deposit of the treatment plan may be required before treatments or hospitalization of your pet. I recognize that any financial concerns should be discussed PRIOR to examination and treatment consent. We accept cash, debit, or all credit cards. We also offer Care Credit or Scratch Pay.(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

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)

MM slash DD slash YYYY

File Upload

Drop files here or

Max. file size: 256 MB, Max. files: 5.

Do not close the browser until you see the form success message, please.

CAPTCHA