New Client Form -Evergreen Animal Hospital

Evergreen Animal Hospital

32175 Castle Court
Evergreen, CO 80439-9585

(303)674-4331

www.evergreenvet.com

               New Client Form

                              32175 Castle Court
                              Evergreen, CO 80439


Please make sure to call us and make an appointment. 303-674-4331. If you are new client, and would like to speed up your check-in process when you arrive at our office, please complete the form below and submit.

New Client

Your Name *(required)*

First Name (required)	Last Name (required)

Mailing Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Street Address *(required)*
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Home Phone (required)
Phone Type	Phone Number (required)

Cell Phone
Phone Type	Phone Number

Work Phone (required)
Phone Type	Phone Number (required)

E-Mail Address (required) :

Emergency Contact informtion

Check if same as above information

Name

First Name	Last Name

Phone
Phone Type	Phone Number

Emergency Persons Relationship:

Patient Infomation

Pet's Name (required)

Pet Age: Years, Months

Type of Pet (required)

Canine
Feline
Avian
Exotic
Other

Breed:

Sex: (required)

Male
Female

Neutered/Spayed (required)

Neutered Male
Spayed Female

Are your pets vaccines current?

Veterinarian Information

Do you have pets medical records with you?

Name of Referring Veterinary Practice & Name of Veterinarian (required)

May we request a transfer of records?

Yes
No

Please list any additional pets here - additional forms available at checkin.

Just one question for helping us get the word out!

How did you hear about us? (required)
(Please choose one )

Referring Doctor
Friend
Dex
Mountain Book(Echo)
Web Search
Outdoor Sign
Local Paper
Local Charity
Pet Supply Store

Financial Terms

Drivers License #, State, Expiration (required)

Emergency Care Directive

In case of an emergency
Please allow Evergreen Animal Hospital (EAH) to make decisions for the care of my pet in case of an emergency. If my animal is transported to this facility, I will be responsible for all payments. Evergreen Animal Hospital will keep a copy of this form in our records.

I have read this emergency care financial agreement and -

I agree
I disagree

Emergency Care Request
Evergreen Animal Hospital will try to contact you as soon as possible if your pet is brought in as an emergency. If I cannot be consulted, I wish for Evergreen Animal Hospital to (Please mark only one)

Choice of care

Take care of my pet to the best that EAH can deliver and I will be responsible for all services rendered.
Only stabilize my animal until I can be consulted. This typically would include oxygen, fluids and pain medication if needed. Hospitalization charges will still apply for all hours my pet is in the care of EAH and I will be responsible for all charges.
I don't want my animal cared for if I'm not present. The care giver of my animal will be sent home without service preformed.

THANK YOU
Thank you for allowing Evergreen Animal Hospital to provide for your pets health care needs.

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