UPDATED CLIENT & Patient Information Form

UPDATED CLIENT & Patient Information

Form

Owner:(Required)

First Last

Has your address changed?(Required)

Yes

My current address is:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home phone(Required)

Cell Phone(Required)

Do you prefer to be called or texted for appointment reminders and follow ups?(Required)

Call

Text

No preference

Has your email changed:(Required)

Yes

Update my email address to:

please provide the best email address this is how reminders and forms are sent. They come from centennialpets@gmail.com if you need to allow incoming emails.

Co-Owner Or Authorized Person(s)

Authorized to bring your pet in. (must be over 18yrs of age)

Name

First Last

Phone

Name

First Last

Phone

Add Another Person?

Yes

Emergency Contact

Name:(Required)

First Last

Phone:(Required)

Please verify all the pets currently in your household:

Pet Name #1

K-9 or Feline

Add Another Pet?

Yes

Pet Name #2

K-9 or Feline

Add Another Pet?

Yes

Pet Name #3

K-9 or Feline

Add Another Pet?

Yes

Pet Name #8

K-9 or Feline

Office Policies

To allow 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, otherwise you may need to schedule a follow up appointment to address additional concerns. 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)

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)

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 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)

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(Required)

Yes

Signature of Owner:(Required)

Date:(Required)

MM slash DD slash YYYY

CAPTCHA

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