Technician Form

Thank you for giving Centennial Animal Hospital the opportunity to care for your
pet(s).

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)

Who should we contact to make medical decisions today?(Required)

Myself

Someone else

Name(Required)

First Last

Phone(Required)

Reason for visit (check all that apply):(Required)

Dog vaccine booster, please specify which one(s) below

Feline vaccine booster, please specify which one(s) below

Anal gland expression

Nail trim

Ear cleaning

Blood testing previously recommended by veterinarian

Urine testing previously recommended by veterinarian

Heartworm/tick test (dogs)

FELV test (cats)

SQ fluid therapy

Cytopoint injection

Other

If other, please specify(Required)

Dog Vaccines(Required)

Distemper/Parvo DA2PP

Leptospirosis

Canine Influenza Bivalent (H3N2 & H3N8)

Rattlesnake

Cat Vaccines(Required)

FVRCP/Distemper

Feline Leukemia (FeLV)

Flea/Tick/Heartworm prevention:(Required)

Do you need to take home heartworm prevention today?(Required)

Yes

For in-clinic purchase of 6 months of Interceptor Plus, get one dose free; with the purchase of 12 months, receive a $15 manufacture mail in rebate.

How would you like to purchase your heartworm prevention?(Required)

In house - 6 month supply

In house - 12 month supply

Online pharmacy

Written prescription (can be mailed to the online or local pharmacy of your choice)

Do you already have an account with our online pharmacy, Myvetstore?(Required)

Yes

Please enter the email that we can set up an account for you(Required)

Do you need to take home flea/tick prevention today?(Required)

Yes

For in-clinic purchase of Nexgard: 3 months get a free dose; 6 months get a $15 manufacture mail-in rebate; 12 months get a $35 manufacture mail-in rebate

How would you like to purchase your flea/tick prevention?(Required)

In house - 6 month supply

In house - 12 month supply

Online pharmacy

Written prescription (can be mailed to the online or local pharmacy of your choice)

Do you already have an account with our online pharmacy, Myvetstore?(Required)

Yes

Please enter the email that we can set up an account for you(Required)

Have you noticed any issues/problems with your pet within the last 3 days? (check all that apply)(Required)

Decrease in appetite

Decrease in drinking

Coughing/sneezing

Vomiting

Diarrhea

Urination issues

Scooting

Difficulty rising

Other

None of the above

If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?(Required)

If other, please specify(Required)

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

Yes

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

I understand that financial responsibilities for services are rendered at the time of service, we are happy to provide estimate for additional services on request.(Required)

I have read and understand

I give Centennial Animal Hospital authorization to treat as discussed above.(Required)

I have read and understand

Critter concierge: During the duration of the exam, your pet will be in the care of one of our team members. A team member will collect your pet from the car and support them through the exam, any services required, and then bring them back to your vehicle at the end of the appointment. Unless otherwise noted, your pet’s care will be performed while you remain in the parking lot. A veterinarian or technician will call you in your vehicle to discuss your pet’s exam and discuss recommended treatments or preventative measures.(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.(Required)

I certify

Signature(Required)

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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

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