Name *

First

Last

Pronouns

Email *

Primary Phone *

Is this primary phone a *

Cell Phone
Landline

Secondary Phone

Secondary Phone Owner - Is this your phone number or someone else?

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Drivers License Number

Drivers License State

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Authorized decision makers

Previous Veterinarian Name *

Previous Veterinarian Phone *

Pet Information

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Do you have insurance for your pet? *

No
Yes

Who is your policy with? *

Sex *

Male
Neutered Male
Female
Spayed Female

Known Problems

Does your pet experience stress/anxiety at the vet? If yes please explain:

Do you have another pet to add? *

No
Yes

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Do you have insurance for your pet? *

No
Yes

Who is your policy with? *

Sex *

Male
Neutered Male
Female
Spayed Female

Known Problems *

Do you have another pet to add? *

No
Yes

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Do you have insurance for your pet? *

No
Yes

Who is your policy with? *

Sex *

Male
Neutered Male
Female
Spayed Female

Known Problems *

Do you have another pet to add? *

No
Yes

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Do you have insurance for your pet? *

No
Yes

Who is your policy with? *

Sex *

Male
Neutered Male
Female
Spayed Female

Known Problems *

Do you have another pet to add? *

No
Yes

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Do you have insurance for your pet? *

No
Yes

Who is your policy with? *

Sex *

Male
Neutered Male
Female
Spayed Female

Known Problems *

Social Media Policy

Patients may be featured with a picture, first name and age on social media (facebook, instagram, website, the next hot new thing). If you do not want us to share your super cute puppy, handsome cat, or distinguished senior pet, please let us know. *

Yes, share my pets photo.
No, do not share my pet's photo.

Prescription Policy

We can fill medications here at Wildflower Veterinary Hospital or provide a written prescription for clients with a current VCPR. We do not fax or call any pharmacy. *

Please type Yes, I understand.

View the full policy.

Emergency Care

We are a daytime general practice facility and refer to other clinics for after hours care. *

I understand.

We are a small privately owned local business. Payment in cash or credit card is due at the time of service. *

I understand.

If your pet is brought in by a pet sitter, good samaritan, someone not on the authorized list, etc and your pet is critical do we have your permission to provide emergency care up to a cost specified below if our veterinarian deems it necessary? *

Yes
No

Up to what cost do you authorize?

We try to accommodate as many patients as possible. When appointments are missed it means another patient may have delayed care or be sent to the emergency veterinarian. If you miss an appointment without 24 hours advance notice, all future appointments will be charged a non refundable scheduling fee that will be applied to your visit. *

I understand

How many hours notice is expected to cancel appointments? *

"We strive to create a space of mutual respect and integrity to provide optimal care for pets and their families.” If a client treats any member of the staff with disrespect in person or online (cursing, yelling, physical aggression, intimidation, threats, etc) we will consider this a termination of the VCPR and will send your records to a veterinary office of your choosing. *

I understand.

To serve all of our clients with equal respect-- if you are late beyond 10 minutes your appointment will need to be rescheduled and all future appointments will be subject to a rescheduling fee. This fee will be applied against the costs of the visit and is forfeited for "no-show" appointments. *

I understand.

We require all animals be on a leash or in a carrier whenever entering/exiting the building or in the lobby. This is for the health and safety of both our clients and their pets. *

I understand.

All incoming and outgoing phone calls are recorded (as Colorado is a one party consent state). All public areas of the clinic are on video/audio recording. If any chargebacks are done or false reviews, Wildflower Veterinary Hospital reserves the right to share these audio or video recordings (or summaries thereof) with the credit card companies, the police, or on social media as needed to protect against defamation or theft. *

Please type "Wildflower" to get past question.

Rabies vaccine is required for all patients unless contraindicated by previous documented anaphylactic reaction or a current cancer/autoimmune diagnosis. *

Please type "Rabies" to get past question.

New Client Form

New Client Form

Pet Information

Social Media Policy

Prescription Policy

Emergency Care

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