Check-In / Drop off

Centennial Animal Hospital Check-In / Drop off Form

Thank you for giving Centennial Animal Hospital the opportunity to care for your pet(s). During this time, we are asking all clients to fill this out prior to any doctor appointments

Please note: In order to schedule an appointment, please call our team or click here. Please schedule your appointment prior to completing the check-in form below.

* indicates it is a must fill out line.

I am in this vehicle: *

(list make, model & color)

Best phone number for your appointment: *

Email *

Patient's Name *

Patient's Species *

Owner's Name *

First

Last

Appointment Date/Time *

//Date

Time

Primary Reason for Appointment: (please be as detailed as possible) *

Any other problems or concerns you would like the doctor to know about?

Has your pet had any of the following symptoms within the last week? (check all that apply) *

Coughing
Sneezing
Discharge
Vomiting
Diarrhea
None

What Brand and type of food do you feed? How much and how often?

Has your pet's appetite been:

Normal
Increased
Decreased

Has your pet's water intake been:

Normal
Increased
Decreased

Is your pet on heartworm prevention?

Do you need a refill?

If yes, please provide name of medication

Is your pet on Flea/Tick Prevention?

Do you need a refill?

If yes, please provide name of medication

List any current medications (including prescription, over the counter, vitamins and supplements) your pet is or recently has been taking.

Do you need any refills?

Name of medication, how much and how often are you giving it and quantity you want.

Does your pet travel out of state?

Owner's Signature *

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.

Phone

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