Small Animal New Client Form

The Small Animal Clinic at CEC

To confirm your appointment please complete this form 72 hours prior to your appointment time so we can assure we are able to get all of the information we need to make your pet’s experience at our clinic an enjoyable one.

If this form is not completed 48 hours prior to your pet’s appointment time we will not be able to save their time and will have to open it up for other patients.

Client Information

Owner's Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

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

Type of Phone(Required)

Cellphone

Home

Work

Preferred Method of Contact(Required)

Phone

Text

Secondary Contact Name

First Last

Secondary / Home Phone Number

Emergency Contact (If different than above)

First Last

How did you hear about us?(Required)

Signage

Social Media

Internet

Personal Reference

Other

Patient Information

Pet's Name(Required)

What is your pet's age or birthday?(Required)

Species(Required)

Dog

Cat

Other

What breed is your pet?(Required)

Color / Markings(Required)

Sex(Required)

Male

Female

Is your pet neutered / spayed?(Required)

Yes

What date was your pet neutered/spayed?

Is your pet:(Required)

100% Indoors

Indoor / Outdoors

100% Outdoors

Is your pet micro-chipped?(Required)

Yes

Microchip Number

Medical & Vaccination History

Does your pet take any medications or supplements?

Yes

Current medications / supplements (Name, Strength, Dosage)?

Has your pet been de-wormed?(Required)

Yes

Is your pet on; (select all that apply)(Required)

Heartworm Preventative

Flea Preventative

Tick Preventative

None

Which one?(Required)

Does your pet have any known medical conditions or a history of prior surgeries?(Required)

Yes

Does your pet have any known allergies or reactions to vaccinations?(Required)

Yes

Does your pet need any special handling needs or is there anything we can do to make your pet's visit more enjoyable?(Required)

Yes

Do you have other pets in the home?(Required)

Yes

Does your pet frequent public places or board?(Required)

Yes

Does your pet travel between states?(Required)

Yes

Previous Vaccinations

Please enter date last given

Bordatella / Parainfluenza

Rabies

Distemper (DAPP/DAPPL)

Lepto

Please provide the name and contact information of your previous veterinary clinic*

Please attach any medical records/vaccination records

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 32 MB.

If there are any additional details, comments or needs you would like to share with us regarding your pet at this time, please use the space provided below.

Do you have any other pets you would like to add to our records at this time?(Required)

Yes

Authorization for Care

By signing below, I am the owner (or authorized agent of the owner of) of my pet. I hereby authorize The Small Animal Clinic at Colorado Equine Center, its veterinarians, technicians, and assistants to perform services, procedures, diagnostics, vaccinations, treatments, and/or administration of extra-label medications as deemed necessary or advisable in connection with or relating to matters described in the attached estimate (If requested) or the matters that otherwise been explained by the hospital veterinarian or other hospital associate.

I understand that there is a risk of complications with every procedure, including the possibility of death as a severe complication of surgery, anesthesia, or other procedure. I also understand that there is no guarantee as to the results of any procedures, diagnostics, vaccinations, or treatments. I understand that I may ask any questions that I have regarding any procedure, diagnostic, vaccination, or any treatment recommended by the veterinarian before it is performed.

I authorize The Small Animal Clinic to obtain all medical records regarding my pet from other hospitals where my pet has previously been examined or treated.

I understand that there may always not be a veterinarian at the hospital. I understand that veterinary technicians or assistants may perform certain functions in the preparation and care of my pet even when a veterinarian is not present. I also understand that a veterinarian will not be at the hospital overnight and unless the veterinarian advises that my pet may remain unattended in the hospital overnight, I will need to take my pet home or transfer my pet to a hospital offering overnight care at the end of the day. I if fail to pick up my pet by the end of the day I understand that The Small Animal Clinic may transfer my pet to a hospital offering overnight care if the veterinarian determines that my pet cannot be left unattended overnight. I understand and agree that I am responsible for the payment of any charges for overnight care.

I agree that The Small Animal Clinic may walk my pet outside. I understand in the event of an emergency, it may be necessary for my pet to be taken to an emergency hospital. I authorize The Small Animal Clinic and its veterinarians and other personnel to transport my pet to an emergency hospital and to obtain treatment by the emergency hospital to stabilize my pet if I cannot be reached. The Small Animal Hospital may disclose such information and records regarding my pet to the other hospital as they consider necessary.

If I neglect to pick up my pet within 7 days, The Small Animal Clinic may assume that my pet has been abandoned and is authorized to make such an arrangement as it may deem best.

Payment Authorization

I understand that payment is due, in full at the time services are rendered in order to keep costs low for all clients. If for any reason payment is not made at the time services are rendered, I understand my account may be referred to a collection agency.For your convenience, we accept Visa, Mastercard, American Express, Discover, cash, check, and select Care Credit plans.

Media Release: I authorize The Small Animal Clinic at Colorado Equine Clinic the right to take photographs, video, or sound recording of my pet(s) to be published for research, educational & promotional purposes. Names will be kept anonymous but media may be seen in a public environment(Required)

I agree

I do not agree

Signature(Required)

Please sign: This signature certifies that you own the above described animal (s), that you authorize the Small Animal Clinic at Colorado Equine Clinic to provide care, and that you agree to provide payment at the time of service, as outlined above.

Date(Required)

Phone

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

Small Animal New Client Form

The Small Animal Clinic at CEC

Client Information

Patient Information

Medical & Vaccination History

Previous Vaccinations

Authorization for Care

Payment Authorization

Contact Us

Clinic Hours of Operation