Patient Admission Form | Emergency Pet Clinics in Boulder

Boulder Emergency Pet Clinic

If your pet is in respiratory distress, please call (303) 440-7722 and let the staff know immediately.

Is your pet having difficulty, rapid or labored breathing? If so please alert us immediately when you get here.

Yes

No

Unsure

Pet Guardian Information

First Name

Last Name

Address

City

State

Zip Code

Phone

Email

Secondary Contact Name

Secondary Contact Number

Pet Information

Pet's Daytime Veterinary Clinic

Pet's Name

Pet's Age

Pets Sex

Animal type

If other animal type, please describe

Breed

Color or markings

Presenting Problems or Symptoms

Select all symptoms that your pet is experiencing.

Describe other symptoms

How long has your pet had these symptoms?

Is your pet currently up-to-date on vaccines?

Is your pet currently on any medications?

If yes, please list all current medications and last dose.

Please describe any important medical history or other important information we need to know about.

Have you traveled outside of the state or country with your pet recently?

Payment

A deposit or payment is required for all hospitalized patients.

We are unable to extend credit or to bill you later. If there is a problem regarding payment, please advise the staff immediately.

An estimate will be given to you for all hospitalized patients. If you would like an estimate for outpatient treatment, please inform the doctor prior to treatment. Personal checks will only be accepted on a preprinted check from a bank in the Denver/Boulder metro area, with a current driver's license or official ID, work phone, and valid address. No third party payments of any kind or PO boxes will be accepted. All checks are verified through Collection Service Solutions.

I understand

Authorization & Content for Treatment

I am the guardian or the agent for the guardian, of the above described animal and have the authority to execute this consent.

I authorize the Boulder Emergency Pet Clinic to treat the above described animal and understand that this treatment may include the use of appropriate anesthetics, medications, and/or surgery and I realize that results cannot be guaranteed.

I accept full financial responsibility for all fees to be paid in full at the time of release of the animal.

Any animal not picked up within the time required by Sec 12-64-115, C.R.S. 1973 as amended shall be deemed abandoned by the owner and will be disposed of
according the above statute.

I have read and understand this authorization and consent for treatment. I acknowledge that by choosing I understand that I am electronically signing this document.

I understand

I understand that if I have NOT already spoken with a staff member, I will call (303) 440-7722 to notify the clinic of this incoming submission form.

I understand

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Admission Form for Boulder

Boulder Emergency Pet Clinic

Pet Guardian Information

Pet Information

Presenting Problems or Symptoms

Payment

Authorization & Content for Treatment

Emergency Vet Care

Location & Phone

Hours