Mountain Ridge Animal Hospital and Pain Management Center

Mountain Ridge Animal Hospital & Pain Management Center

New Client Check In     

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - MOUNTAIN RIDGE NEW CLIENT FORM

Name (required)
First Name (required)
Last Name (required)
Social Security #

Driver's License #; Issuing State

Spouse/Other Name
First Name
Last Name
Social Security #

Driver's License #; Issuing State

Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Evening Phone (required)
Phone TypePhone Number (required)
Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :
Breed: (required)

Sex: (required)
Male
Female

Neutered/Spayed (required)
Neutered
Spayed

Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice? (required)
Yes
No

Name of Former Veterinary Practice (required)

May we request a transfer of records? (required)
Yes
No

Would you like us to call you for your appointment
Reasons or conditions that prompted your visit? (required)

Special requests or conditions?

Text Area

Please list any additional pets here (required)

MOUNTAIN RIDGE ANIMAL HOSPITAL is dependent upon your payment of fees to maintain our high quality
of patient care. The hospital does not extend credit (Bill) and you are responsible for all fees for products and services rendered. We will be glad to provide an ESTIMATE FOR SERVICES at any time. A deposit will be required prior to initiating treatment.
AUTHORIZATION for EXAMINATION, TREATMENT, and ASSUMPTION OF FINANCIAL RESPONSIBILITY
I, the undersigned, authorize the veterinarian(s) and their staff at MRANH to examine the patient specifically described and identified above and to administer any medical, surgical, treatments and/or tests including sedation or anesthesia which is considered necessary based on findings during the course of examinations. I, assume responsibility for all charges incurred for services rendered to the patient. I understand there is a $25+ service charge for returned checks and that unpaid accounts accrue a $15 late fee after thirty (30) days, plus interest at the rate of 1.5% per month (18% per annum) compounded monthly. If collection action is necessary on this account, I agree to pay all costs of collection, plus attorney fees, whether or not a suit is filed. The parties agree to the exclusive venue and jurisdiction of the City of Lafayette, Colorado, for all matters arising from this agreement.
I have read this statement and - (required)
I Agree
I Disagree


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