Client and Patient Registration "*" indicates required fields Client InformationClient Name* Address* Street Address City State / Province / Region ZIP / Postal Code Phone (Primary)*Phone (Secondary)Phone (Other)Which number is best for today?* Primary Secondary Other Email* Additional Authorized Guardian Authorized Guardian PhoneEmergency Contact Name* Emergency Contact Phone*Family Veterinarian* Is this your first visit?* Yes No How did you hear about us?*Please check all that apply Family Vet Family / Friends Facebook Website Previous Visit News Radio Internet Drove by Event Other (Other) Are there any other pets in the house? Dogs Cats Other (Other) Does your pet have pet insurance?* Yes No Who with? Patient InformationPatient Name* Species* Breed* Sex* Color* Weight* Is your pet spayed/neutered? Yes Age* Reason for your visit:* Date of last rabies vaccine MM slash DD slash YYYY Rabies vaccination administered by: Any known drug allergies or vaccine reactions?* Diet* Current medications, flea/tick and heartworm prevention: Add RemoveAny recent travel outside of Colorado or to the mountains? Where/when? I am the owner or authorized agent of the animal listed above, and being over the age of 18, I authorize Veterinary Specialists of the Rockies, its staff and contracted agents to perform medical and initial diagnostic/surgical procedures on my pet as required for diagnosis and treatment. Veterinary Specialists of the Rockies takes all possible care in the treatment and handling of animals, but cannot assume responsibility in the case of fire, theft or escape. I assume full responsibility for all charges incurred for the care of my pet and understand these charges will be paid as the services are rendered. I also acknowledge that deposits may be required for procedures, hospitalization or surgical treatment. I understand that as the owner or agent I am financially responsible for all charges relating to this patient. I have reviewed this patient registration form and provided the most up to date and accurate patient and client information I have available. I have also read and agreed to this treatment authorization, the financial obligation and for use of photos on social media and for educational purposes.I, the undersigned owner, or authorized agent of the owner responsible for seeking veterinary care for the pet identified above, certify that I am over eighteen years of age, and hereby consent to the examination of this pet by Veterinary Specialists of the Rockies (VSR). I also agree that after consultation with me, the hospital’s doctors may initiate treatment on my pet. Should some unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me, this practice’s staff has my permission to provide such treatment and I agree to pay for all related fees. No certain outcome is guaranteed in veterinary medicine. I am also aware that certain breeds may have higher risk during procedures or treatment due to their physical conformation. I understand that I can terminate treatment at any time by contacting my pet’s attending doctor. Cardiopulmonary Resuscitation (CPR) DirectiveI understand Veterinary Specialists of the Rockies (VSR) requires a CPR status prior to the start of any and all procedures so immediate action can take place in the event of cardiopulmonary arrest during, before, or after anesthesia or anytime in our care. I acknowledge that the attending veterinarian or staff members of VSR will make every effort to contact me regarding treatment in the case of this unforeseen event. The starting cost of CPR is approximately $400.I am the owner / agent of this pet and ...* DO AUTHORIZE CPR efforts for my pet DO NOT AUTHORIZE CPR (DNR) efforts at this time Date MM slash DD slash YYYY Owner/Agent Signature*NameThis field is for validation purposes and should be left unchanged. Δ
