New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client

Name (required)
First Name (required)
Last Name (required)
Spouse/Other
First Name
Last Name
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Mailing Address (if different)
Street Address
City
State/Province
Zip/Postal Code
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Employer (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Employer Phone (required)
Phone TypePhone Number (required)
How Did You Hear About Us? (required) :
Name of Individual or Hospital (or type N/A) (required)

Pet's Name (required)
First Name (required)
Last Name (required)
Age: Years, Months

Type of Pet (required) :
Breed:

Color/Markings

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here (required)

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Longs Peak Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Longs Peak Animal Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. We accept cash, personal checks, Visa, MasterCard and CareCredit. We do NOT accept American Express, Discover or business checks over $100.
I have read this statement and - (required)
I Agree
I Disagree


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