to have to

Client Information

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone *

Spouse/Partner’s Name

Spouse/Partner’s Phone Number:

Any special instruction to get to your home (building location, special parking instructions, etc.)?

How did you hear about us?

We really value and appreciate you thinking highly enough to refer us to your friends, family, and coworkers. To say thank you, we apply a $15 credit to your account and your friend’s account during their first visit. *

Social Media Release

We love adding pictures of our patients to our social media, office slideshows, website, and newsletters! Do we have permission to use images of your pet(s) on our social media and other sites? *

Yes
No

Mobile Visits

For large animal mobile visits, I understand that my animal(s) should be caught and in hand or tied, ready for their examination and/or treatment. Horses should be lightly groomed with no fly spray or coat conditioner applied. *

I Agree and Understand

For small animal mobile visits, I understand that my pet(s) should be in a confined area, ready for their examination and/or treatment. *

I Agree and Understand

Signature *

Clear Signature

Hospital Policies and release of Liability

I, the undersigned, am 18 years of age or older and am the owner/responsible party. I authorize the examination and treatment of my animal(s). I acknowledge receiving services and certify that I will take financial responsibility for incurred expenses. I understand that payment is due at the time of service. There is an additional fee of $40.00 for returned checks and disputed credit/debit card charges. If my account is past due 30 days, I hereby agree to pay in addition to the amount due, a 1.5% per month (18% per annum) interest rate on outstanding charges. *

I Agree and Understand

I understand that all animals brought into the hospital are required to be on a secure leash or in an appropriate carrier. *

I Agree and Understand

To provide the best possible care for my pet(s), I understand that mutual kindness and respect is necessary for a collaborative relationship. I understand that threats, yelling, and mistreatment of any type will not be tolerated. *

I Agree and Understand

There is an inherent risk in participating in activities involving animals. I agree to not hold Colorado On-Site Veterinary Service, Inc (COVS) or any people working under the direction of COVS liable for any injury to my person, animal, or damage of equipment or facility. *

I Agree and Understand

I understand the Cancellation Policy: appointments cancelled or rescheduled within 48 hours of the scheduled appointment will be charged a $90 fee. All payments are due at time of service and we accept the following payments: cash, check, debit and credit. There is a 3.5% fee on credit card transactions. *

I Agree and Understand

I’ve read and understand the policies listed in this document and agree to comply with them. *

I Agree and Understand

Signature (copy) *

Clear Signature

Signature of Witness *

Clear Signature

Date *

Client Information Form and Agreement Form

Fill Out Our Client Information Form and Agreement Form