Client and Patient Registration Name First Middle Last Additional Authorized Guardian (1)Phone (1)Additional Authorized Guardian (2)Phone (2)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone (Home)Phone (Cell)Phone (Work)Which number is best for today?HomeCellWorkWhich number is best for overnight?HomeCellWorkEmail Would you like to join our newsletter? Yes Emergency Contact First Last Emergency Contact PhoneFamily VeterinarianIs this your first visit?YesNoHow 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? Dog Cat Other (Other)Patient InformationPet's NameSpecies Canine Feline Other (Other)Breed Male Female Spayed Neutered ColorDate of last rabies vaccine Date Format: MM slash DD slash YYYY Rabies vaccination administered by:Any known drug allergies or vaccine reactions?DietCurrent medications, flea/tick and heartworm prevention:Any recent travel outside of Colorado or to the mountains? Where/when?Reason for your visit: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.Client / Authorized Agent Initials Client Visit Pet FAQs Resources
