New Client InformationToday's Date* MM slash DD slash YYYY Your Name* First Last Pronouns*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Consent I consent to receive SMS text messages from COLORADO CAT CLINIC for appointment reminders, marketing messages, and general two-way communication.Msg frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out. See our privacy policy for more information. Email Address* Additional pet guardian First Last PronounsIs this person authorized to make care decisions for your pet?* Yes NoOther Contact NumberWork Phone*Employed by*Emergency contact*Emergency Contact Phone*How did you hear about us?*Preferred Contact Method* Home Cell WorkHow would you like to receive reminders?* Phone call Text messageDo we have permission to share your pet’s photo on our website and social media?* Yes NoFor the safety of all our patients and to prevent the spread of infectious diseases and parasites such as intestinal worms, ear mites and fleas, hospitalized animals must be current on recommended vaccines and free of internal and external parasites. Also, for the protection of your family and our staff, we request that all animals be kept current on rabies vaccinations. Please authorize preventative health services by initializing the box below:*I authorize vaccinations and parasite control for my pet should the pet require it.* I authorizeBILLING POLICYAll payment is due at the time services are rendered. We accept cash, check, most major credit cards and Care Credit. Estimates can be provided. We do not bill unless a payment plan has been established prior to receiving services. Monthly payments are required on payment plans to prevent late fees. If payment is not received within 90 days of service, your account may default to collections.CANCELLATION POLICYIf an appointment needs to be cancelled or rescheduled we appreciate 24 hours notice. We require 72 hours’ notice for cancellation of any surgical or dental procedure. Failure to notify us within this time frame may result in a cancellation fee being charged to your account.By signing below, you acknowledge and understand the billing & cancellation policies and accept financial responsibility for your account.Signature*CAPTCHANameThis field is for validation purposes and should be left unchanged.Δ
