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Vet Services
Pet Wellness
Pet Urgent Care
Pet Vaccinations
Pet Surgery
Spay and Neuter
Pet Dental Care
Pet Parasite Prevention
Stance Analyzer
Laser Therapy
End of Life Services
About
About Us
Our Veterinarians
Our Staff
Current Clients
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New Client Information
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New Client Information
New Client Info
Client Information
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip Code
*
Email
*
Phone
*
Were you referred by a family member or friend?
Yes
No
Please enter the name of who referred you.
Spouse or Co-Parent Name
Spouse or Co-Parent Phone
Spouse or Co-Parent Email
Alternate Emergency Contact Name
Alternate Emergency Contact Phone
Pet Information
Number of Pets
*
1
2
3
4
Pet 1
Name
*
Species
*
Dog
Cat
Exotic
Breed
*
Color/Markings
*
Age or DOB
*
Male/Female
*
Male
Female
Spayed/Neutered?
*
Yes
No
Microchip #
Pet 2
Name
*
Species
*
Dog
Cat
Exotic
Breed
*
Color/Markings
*
Age or DOB
*
Male/Female
*
Male
Female
Spayed/Neutered?
*
Yes
No
Microchip #
Pet 3
Name
*
Species
*
Dog
Cat
Exotic
Breed
*
Color/Markings
*
Age or DOB
*
Male/Female
*
Male
Female
Spayed/Neutered?
*
Yes
No
Microchip #
Pet 4
Name
*
Species
*
Dog
Cat
Exotic
Breed
*
Color/Markings
*
Age or DOB
*
Male/Female
*
Male
Female
Spayed/Neutered?
*
Yes
No
Microchip #
Current Veterinarian
Would you like us to contact a previous vet for records for your pet?
Yes
No
Previous Clinic Name
Acknowledgment and Signature
I understand that payment is expected at the time services are rendered. I hereby authorize the staff of Boulder Veterinary Hospital to render any treatment which is deemed necessary to the health of my pet(s) while in custody of the hospital. I understand that in the event of any unusual or emergency circumstances, the staff will make every attempt to contact me or my designated representatives before, if time permits, proceeding with the treatment. I understand that I will be financially responsible for all emergency procedures including the Estimate of Charges provided to me in person or over the telephone. I understand that a deposit is required for all pets admitted to the hospital. I understand that if my account is not kept in good standing, a finance fee of $25 will be added to the account and it will be forwarded to a third-party collections agency, which may affect my credit rating. I understand that photos/videos may be taken of my pet for training or marketing purposes.
*
I have read and agree to the statement above.
Signature of Owner / Agent / Good Samaritan
*
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