Contact Information
Owner Name
*
First Name
Last Name
Owner Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Co-Owner's Name & Contact Information
First Name
Last Name
Co-Owner's Phone Number
Please enter a valid phone number.
How did you hear about us?
*
Walked/Drove By
TV/Radio/Newspaper
Hospital Employee
Google/Bing/Yahoo
Card/Flyer/Mailer
Facebook/Instagram
Boarding/Grooming
Yelp
Shelter
Other - (Existing Client, Hospital/Veterinarian, etc.)
Please use this area to give us any other relevant information about yourself, family, and other pet's in the household:
Pet Information
Pet's Name
*
Species
*
Dog
Cat
Rabbit
Ferret
Bird
Reptile
Or if other species
Breed (if known)
*
Color
*
Date of Birth or Age (if known)
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Unknown (for Reptiles)
Spayed/Neutered
Yes
No
Microchip #
Special Identification (tattoos, microchip, etc.)
Previous Veterinary Practice (if any)
*
Date of Last Vaccines (if known)
-
Month
-
Day
Year
Date
What vaccines were given at this time?
Is your pet on any medication or supplements?
Yes
No
If yes, please list medications(s) and supplement(s).
What food does your pet eat?
Does your pet have allergies or drug reactions?
Yes
No
If yes, please list allergies and reactions.
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions.
Please use the following box to give us any other relevant information about your pet.
Do you have another pet to add?
Yes
No
Pet #2 Information
Pet's Name
*
Species
*
Dog
Cat
Rabbit
Ferret
Bird
Reptile
Or if other species
Breed (if known)
*
Color
*
Date of Birth or Age (if known)
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Spayed/Neutered
Yes
No
Microchip #
Special Identification (tattoos, microchip, etc.)
Previous Veterinary Practice (if any)
*
Date of Last Vaccines (if known)
-
Month
-
Day
Year
Date
What vaccines were given at this time?
Is your pet on any medication or supplements?
Yes
No
If yes, please list medications(s) and supplement(s).
What food does your pet eat?
Does your pet have allergies or drug reactions?
Yes
No
If yes, please list allergies and reactions.
Are there any current or past medical conditions of which we should be aware?
Yes
No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions.
Please use the following box to give us any other relevant information about your pet.
Photo Consent: We love social media! Do we have your permission to share your pet(s)' image and story on social media, our website, and other forms of related media? Your name and personal information will never be shared. Simply check below to authorize this.
Yes, I authorize Highlands-Eldorado Veterinary Hospital to share my pet's photo and story.
No, I do not authorize this.
Treatment Consent: I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due IN FULL at time of service and that a deposit may be required for hospitalization and surgical procedures. I recognize that financial concerns should be discussed PRIOR to examination and treatment. The Highlands-Eldorado Veterinary Hospital staff is happy to provide estimates. I understand that Highlands-Eldorado Veterinary Hospital does not bill.
Today's Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: