New Patient / Client Information Mile High

New Patient / Client Information
Owner Information
Owner's Name

First NameLast Name
Preferred Pronouns
Spouse / Companion Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Spouse / Companion Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
In case of emergency, and you are unavailable, please designate someone whom we can contact in your stead:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relation to you:
How did you hear about our hospital?
MailEmailText Message
We can also send reminders to one other person! To utilize this service, please list their email:
example@example.com
Patient Information
Pet's Name
Pet's Nicknames
DogCat
Breed
Colors / Markings
Approx. Age or Birthday
MaleNeutered MaleFemaleSpayed Female
YesNo
YesNo
Please list your pet insurance provider:
Name of previous / current Veterinarian?
If you have digital copies of your pet's records, please forward them to our email at clientservices@milehighvet.com
our website (www.milehighvet.com)our social media
Please initial the following statements as you understand them:
I understand that payment is due at the time of service and that MHAHA does not accept checks as a method of payment
I understand that every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon all animals which I or my agent present.
I agree to make every effort to cancel any scheduled appointment with 24 hours notice. I agree to pay the cost of the exam fee for that missed appointment.
Today's Date

MonthDayYear
Date
Signature for release
YesNo
Pet's Name
Pet's Nicknames
DogCat
Breed
Colors / Markings
Approx. Age or Birthday
MaleNeutered MaleFemaleSpayed Female
YesNo
YesNo
Please list your pet insurance provider:
Name of previous / current Veterinarian?
If you have digital copies of your pet's records, please forward them to our email at clientservices@milehighvet.com
our website (www.milehighvet.com)our social media
Should be Empty:

New Patient / Client Information

Owner Information

Patient Information