Erie Animal Hospital

720 Austin Avenue, Suite 107
Erie, CO 80516

(303)828-0373

www.erieanimalhospital.com

On-line New Client Form

Client Information
Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
Phone (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Employer Name

Employer Phone Number

Emergency Contact/Number

How did you hear of our clinic?
Sign
Newspaper
Internet
Town Fair
Humane Society
Erie Magazine
Anthem Magazine
Other/Recommendation (Please fill out field below!)
Recommendation, Whom May we Thank?

Number of Pets (please specifiy dogs, cats, other) (required)

Pet Information - please submit one form for each pet
Pet's Name (required)

Please select the species of your pet (required)
Dog
Cat
Rabbit
Other
If your pet is not one of the species listed above, please tell us the species (required)

Sex (required)
Male
Male Neutered
Female
Female Spayed
Breed of Pet (required)

Age of Pet (required)

Color of Pet (required)

Obtained Pet From
Breeder
Friend
Humane Society
Pet Shop
Craig's List
Obtained Pet from Other then selection above:

List Your Pet's Allergies or Sensitivities

Describe Your Pet's Diet

List Your Pet's Prior Health Conditions/Surgeries
List Your Pet's Current Medications (required)

The Reason for your Visit (required)

Pet History (please check all that your pet has received)
Feline Leukemia Test
Feline Leukemia Vaccine
Feline Distemper
Rabies
Leptosporosis
Canine Influenza (Dog Flu)
Canine Distemper/Parvo Vaccine
Heartworm Prevention
Flea and Tick Prevention
Terms and Conditions
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described patient. I am over 18 years of age and assume responsibility for all charges incurred in the care of the patient. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. If paying by check, proof of driver?s license and expiration is required. There is a $20 processing fee for each returned check.
Authorization (required)
Yes- I do accept the terms and conditions
Print Client Name (required)


Verify the reCAPTCHA: