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303-466-1764
M-F: 7am - 5:30pm | Sat: 8am-2pm
12621 Lowell Blvd, Broomfield, CO
Vet Services
Pet Wellness
Exotic Pet Care
Pet Vaccinations
Pet Dental Care
Spay & Neuter
Parasite Prevention
Pet Surgery
Emergency Pet Care
End of Life Services
Our Veterinarians
Current Clients
First-Time Clients
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Vet Services
Pet Wellness
Exotic Pet Care
Pet Vaccinations
Pet Dental Care
Spay & Neuter
Parasite Prevention
Pet Surgery
Emergency Pet Care
End of Life Services
Our Veterinarians
Current Clients
First-Time Clients
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New Client Info
Complete your new client paperwork online to make your first visit as stress free as possible.
New Client Info
Client Information
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip Code
*
Email
*
Phone
*
Were you referred by a family member or friend?
Yes
No
Please enter the name of who referred you.
Spouse or Co-Parent Name
Spouse or Co-Parent Phone
Spouse or Co-Parent Email
Alternate Emergency Contact Name
Alternate Emergency Contact Phone
Pet Information
Number of Pets
*
1
2
3
4
Pet 1
Name
*
Dog/Cat
*
Dog
Cat
Exotic
Breed
*
Color/Markings
*
Age or DOB
*
Male/Female
*
Male
Female
Unknown
Spayed/Neutered?
*
Yes
No
Unknown
Microchip #
Pet 2
Name
*
Dog/Cat
*
Dog
Cat
Exotic
Breed
*
Color/Markings
*
Age or DOB
*
Male/Female
*
Male
Female
Unknown
Spayed/Neutered?
*
Yes
No
Unknown
Microchip #
Pet 3
Name
*
Dog/Cat
*
Dog
Cat
Exotic
Breed
*
Color/Markings
*
Age or DOB
*
Male/Female
*
Male
Female
Unknown
Spayed/Neutered?
*
Yes
No
Unknown
Microchip #
Pet 4
Name
*
Dog/Cat
*
Dog
Cat
Exotic
Breed
*
Color/Markings
*
Age or DOB
*
Male/Female
*
Male
Female
Unknown
Spayed/Neutered?
*
Yes
No
Unknown
Microchip #
Current Veterinarian
Would you like us to contact a previous vet for records for your pet?
Yes
No
Previous Clinic Name
Acknowledgment and Signature
I understand that payment is expected at the time services are rendered. I hereby authorize the staff of Broomfield Veterinary Hospital to render any treatment which is deemed necessary to the health of my pet(s) while in custody of the hospital. I understand that in the event of any unusual or emergency circumstances, the staff will make every attempt to contact me or my designated representatives before, if time permits, proceeding with the treatment. I understand that I will be financially responsible for all emergency procedures including the Estimate of Charges provided to me in person or over the telephone. I understand that a deposit is required for all pets admitted to the hospital. I understand that if my account is not kept in good standing, a finance fee of $25 will be added to the account and it will be forwarded to a third-party collections agency, which may affect my credit rating. I understand that photos/videos may be taken of my pet for training or marketing purposes.
*
I have read and agree to the statement above.
Signature of Owner / Agent / Good Samaritan
*
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Date
*
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