New Client Registration

OWNER:

First Name *

Last Name *

Your Preferred Nickname

Home #

Cell # (if no cell #, type your home # under cell #) *

Home Address *

City *

State *

ZIP *

Please provide Street Address if mailing address is P.O. Box

Primary Email Address *

Employer / Address

Work #

SPOUSE /CO-OWNER:

First Name

Last Name

Cell/Home Phone

Employer / Address

Work #

IF YOU ARE NOT PET’S OWNER (i.e., pet sitter, friend, temporary guardian, other):

Your Name

Relationship to Owner

Your Address

Phone(s)

OTHER EMERGENCY CONTACT (if no emergency contact available, please write “self” below)

Name/Phone *

PLEASE TELL US REASONS YOU’VE CHOSEN OUR HOSPITAL… (Please check all that apply)

REFERRED to AAH by:

If Other:

SPECIAL SERVICES:Pet BoardingDoggie Day CareAcupunctureLaser Therapy

NEW ADOPTION:Local Animal Shelter AdoptionOther

If Other:

YOUR COMMENTS / SUGGESTIONS:

YOUR PETS
For INFECTIOUS DISEASE PREVENTION: ALL Hospitalized, Boarding, and Doggie Day Care pets must be current on vaccinations and free from internal and external parasites. Our hospital will provide any vaccines and fecal testing/treatment your pet may need (with charges assessed at discharge).

PET #1

Pet’s Name *

Species/Breed *

Pet’s date of birth *

Sex *

Spayed / Neutered *

Color *

PET #2

Pet’s Name

Species/Breed

Pet’s date of birth

Sex

Spayed / Neutered

Color

PET #3

Pet’s Name

Species/Breed

Pet’s date of birth

Sex

Spayed / Neutered

Color

PET HISTORY:

If your pet(s) have traveled out of state, please tell us where and when:

Are your pet(s) currently on heartworm prevention medication? *YESNO

Have your pet(s) been microchipped (for Lost Pet Identification)? *YESNO

OTHER HOSPITALS where my pet(s) have been treated:

AAH PAYMENT POLICY

FULL PAYMENT IS DUE AT THE TIME OF SERVICE. We accept all major credit cards, checks (with ID), CareCredit and ScratchPay. Emergency care, hospitalization and extended boarding stays may require a deposit. A 2% finance charge is applied to balances past due over 30 days and an $8.00 processing fee for courtesy billing. Accounts over 90 days past due will be sent to Collections unless special financing is arranged (thru CareCredit or ScratchPay) or (if other financing is not possible) special hospital payment terms are authorized by Hospital Management.

Method of payment I will be using today: *

PET PHOTO PERMISSION REQUEST *

May we include your pet’s photo, first name, and stories in social media, AAH website, hospital advertising or other materials? Pet photos are for in-Hospital use only and are never shared or sold. Please check one box below:

YES, I authorize Arapahoe Animal Hospital to use photos of my pet(s) for the purposes described above.NO, I do not want the Arapahoe Animal Hospital to use photos of my pet(s) for the purposes described above.

TERMS AGREEMENT & RECORDS RELEASE AUTHORIZATION

By typing my full name below, I accept the hospital policies and payment terms outlined on this form. I also authorize Arapahoe Animal Hospital to request and receive my pet’s patient records from other animal facilities as needed, and to release my pet’s patient information from Arapahoe Animal Hospital when requested by other animal facilities, for the health care and treatment of my pet.

NAME of responsible agent for pet: *

Date *

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