Evergreen Animal Hospital

32175 Castle Court
Evergreen, CO 80439-9585

(303)674-4331

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 TypePhone Number (required)
Cell Phone
Phone TypePhone Number
Work Phone (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Emergency Contact informtion
Check if same as above information
Name
First Name
Last Name
Phone
Phone TypePhone 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
Please Read Financial Terms
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 Evergreen 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 Evergreen Animal Hospital's collection agency, and will incur a 40% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and - (required)
I Agree
I Disagree


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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HOURS

Day Open Close
Monday 7:00am 9:00pm
Tuesday 7:00am 9:00pm
Wednesday 7:00am 9:00pm
Thursday 7:00am 9:00pm
Friday 7:00am 9:00pm
Saturday 7:00am 7:00pm
Sunday 7:00am 7:00pm