Client and Patient Registration 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 PhoneFamily 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.Date MM slash DD slash YYYY Owner/Agent Signature Reset signature Signature locked. Reset to sign again PhoneThis field is for validation purposes and should be left unchanged. Δ
