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Preregistration Form

Upon completion of this form, you will have the option to print or download a copy for your form. Should you not be notified of these options, an error occurred and your form did not send properly.

Please be sure to hit the submit button only once to minimize the chances for error.

CLIENT INFORMATION

Referring Veterinarian 1

Referring Veterinarian 2

Referring Veterinarian 3

Other Authorized Representative Information

PATIENT INFORMATION

Are you the pet's owners?

Is this pet co-owned?

Co-owner’s relationship to you:

VACCINE/TITER HISTORY

Canine: Date Performed

Rabies

Distemper

Bordetella

Heartworm Test

Fecal Test

Other

Feline: Date Performed

Rabies

Distemper

Bordetella

Heartworm Test

Fecal Test

Other

PATIENT MEDICAL HISTORY

Please indicate any past surgeries and/or diagnoses that your pet has received in the past:

Please indicate any concerns you have about your pet’s health:

How did you choose us?

Photography Consent (Optional)

I hereby grant permission to Aspen Meadow Veterinary Specialists, its representatives, and employees the right to take photographs of my pet, and to copyright, use, and publish the same in print and/or electronically.

I agree that Aspen Meadow Veterinary Specialists may use such photographs of my pet with or without his/her name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, promotional material, social media and web content for Aspen Meadow Veterinary Specialists.

Discounts

I am 65 years old or older and qualify for a senior discount (10%)?

Consent to Treat

If it becomes necessary during your pet’s visit, do you want us to administer CPR?

I am the owner or the agent of the owner of the above-described pet and have the authority to execute this agreement. I authorize Aspen Meadow Veterinary Specialists to examine and treat the above pet. I accept financial responsibility for the pet and I understand that full payment for diagnostic tests and treatment that I authorize in writing or verbally will be due at the time my pet is dismissed from the hospital. For hospitalized cases, a deposit is required in advance, the balance is due upon discharge from the hospital.

If another veterinarian has referred me to Aspen Meadow, I understand that they will receive a summary of the care and treatment provided in order to ensure that my pet’s care can be continued without interruption. I also understand that Aspen Meadow considers the identification of a referring veterinarian by me as authorization to release records and information to that veterinarian.

Case information and/or photos may be used in teaching, continuing education, and veterinary literature. I authorize release of case/patient information for such purposes. Patient confidentiality will be maintained.

In the event of ownership transfer, I authorize the release of medical information to the new owner of this animal.

Payment must be rendered at time of service. We accept all major credit cards including Care Credit. Personal checks are welcome when accompanied by a driver’s license. If you have any questions regarding your payment, please discuss it with a receptionist before the start of your visit.