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New Client Information Form

Doctor Preference (if applicable):

Dr. Brad Bundy

Dr. Jennifer Barber-Jones

Dr. Noelle Rathmell

Dr. Jamie Marrott

Dr. Rachel Mikolas

Dr. Ashland Buck

Dr. Audrey Clark

Dr. Chesla Sayers

Dr. Paige Hopper

Primary Client Information

Name

First Name

Last Name

Preferred Phone Number:

Cell

Home

Primary Cell Phone

Primary Home Phone

Secondary Phone Number:

Cell

Home

Preferred Secondary Cell

Preferred Secondary Home

Secondary (Spouse/Partner/Family Member, etc.)

Name

First Name

Last Name

Preferred Phone Number:

Cell

Home

Secondary Cell

Secondary Home Number

Additional Phone Numbers (if applicable):

Additional Client Information

Residential Address:

Primary Email Address:

Contact Preference:

Phone

Text Message

Emergency Contact:

Emergency Contact Phone Number:

Previous Veterinary Clinic:

Do we have permission to share a photo/story of your pet(s) on our business social media accounts?

Yes

Pet Information

Name

Age/DOB

Species

Breed

Color

Sex

Altered

Would you like to add additional pet information?

Yes

Name

Age/DOB

Species

Breed

Color

Sex

Altered

Would you like to add additional pet information?

Yes

Name

Age/DOB

Species

Breed

Color

Sex

Altered

Would you like to add additional pet information?

Yes

Name

Age/DOB

Species

Breed

Color

Sex

Altered

Client Referrals

How did you hear about us?

If someone referred you to us, who can we thank?

Please read and initial the following statements:

Accepted forms of payment are as follows: Visa, Mastercard, Discover, American Express, CareCredit, ScratchPay and Cash payments. Any check payments are subject to approval from management.

I understand that an estimate shall be given for all major procedures involving sedation/anesthesia. I understand that a deposit may be requested for drop-off visits, procedures or hospitalization.

I understand that I am responsible for all fees associated with any services approved by myself or my representative.

I understand that I may request an estimate for any recommended or requested services at any point in time.

I understand that payment is due at the time of service for all visits.

I am responsible for the care of all pets mentioned above and the information I have provided on this sheet is as accurate as possible.

**Please note that any accounts associated with Yorkshire for your pet’s care will need to match all the PRIMARY Client Information. We utilize PetDesk (online booking, client access/communication) and Vet’s First Choice (online pharmacy) at our hospital. Without matching information, these programs will not properly sync with your pet’s medical records.**

Print Name:

Signature

Date

MM slash DD slash YYYY

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1815 Dublin Blvd.,
Colorado Springs, CO 80918

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1815 Dublin Blvd.,
Colorado Springs, CO 80918

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Business Hours

Monday

7:00am - 5:30pm

Tuesday

7:00am - 5:30pm

Wednesday

7:00am - 5:30pm

Thursday

7:00am - 5:30pm

Friday

7:00am - 5:30pm

Saturday

8:00am - 1:00pm

Sunday

Closed