New Puppy/Kitten First Examination Form

Centennial Animal Hospital New Puppy/Kitten First Examination 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.

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

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)

Breed(Required)

Color(Required)

Age/Date of Birth(Required)

Sex(Required)

Male

Male (neutered)

Female

Female (spayed)

Where did you get your pet?(Required)

Shelter

Breeder

Pet Store

Online

Friend

Found Pet

Other

If you found the pet, did you have the pet scanned for a microchip and have you alerted the humane society? They will put a hold on the pet before it can be released for new ownership.(Required)

Yes

If other, please specify(Required)

How many days/weeks have you had the pet?(Required)

What kind 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)

Are there any concerns for the following (check all that apply):(Required)

Sneezing

Coughing

Vomiting

Diarrhea

Eating

Drinking

Other

None of the above

If other, please specify(Required)

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

Yes

Unsure

If yes, please explain(Required)

Is your pet on any medications?(Required)

Yes

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

Many of our patients enjoy treats while visiting our office, but if your pet has an allergy, please let us know or bring approved treats.

Can your pet have treats (low fat I/D kibbles, or cheese)?(Required)

Yes

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)

Upload medical records or any necessary information

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Max. file size: 256 MB, Max. files: 10.

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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

Ready to come see us?

Request an appointment online!

APPOINTMENT