Clearview Animal Hospital

3930 S. Hancock Expy
Colorado Springs, Colorado 80911

(719)392-3495

www.clearview.pet

New Patient Check-In / Registration

Please use our form to register. You can also call us at (719) 392-3495 with any questions and we will be happy to help.

If you would instead like to print, fill out, and bring this form to us - please click HERE to download a PDF version of this form.

New Patient Registration

Owner Name (required)

First Name (required)	Last Name (required)

Spouse / Co-Owner Name

First Name	Last Name

Primary/Preferred Phone Number (required)
Phone Type	Phone Number (required)

Secondary Phone Number
Phone Type	Phone Number

E-Mail Address (required) :

Address
Street Address

City ,	State / Province	Zip / Postal Code

Employer

Work Phone
Phone Type	Phone Number

Ok to call work? (required)

Yes
No

How do you prefer to be contacted? (required)

Phone call
Email
Text

How did you first learn of our hospital?

Drive by
Mail Brochure
Online Search
Radio
Facebook
Personal referral

Referred by:

Other source:

Clearview Animal Hospital Financial Policy
Financial Responsibility: I accept full and total financial responsibility for any and all services explicitly requested by myself or my designated agent, as well as services implied under the terms of consents that I or my authorized agent have signed.These services include but are not limited to services provided by Clearview Animal Hospital, its staff, and subcontractors hired by the same on behalf of my animal/pet.

Payment Policy: Payment for all services rendered are due either at the time of dismissal, when services are performed, or upon request and demand at any time. Clearview Animal Hospital does not allow for billing, partial payment, or delayed payment. Clearview Animal Hospital reserves the right to require partial or full deposits before services are rendered.

Price Matching: Our prices are based on the costs at our hospital. Larger retailers are often able to negotiate lower prices, and online retailers have a lower overhead due to not maintaining a storefront. Clearview Animal Hospital is not able to match lower prices found elsewhere, but we are always happy to write you a prescription for you to fill at the pharmacy of your choice.

Forms of Payment Accepted: For your convenience, we accept MasterCard, Visa, Discover, American Express, CareCredit, and cash subject to the conditions noted below.

Check Acceptance: Clearview Animal Hospital does not accept personal checks.

Credit Cards and Debit Cards: Clearview Animal Hospital is happy to take these forms of payment, but they must be processed immediately and the owner of the card must be present.

CareCredit: Clearview Animal Hospital offers CareCredit as a means to pay veterinary bills; this can be lifesaving in emergencies. CareCredit is a healthcare credit card for treatments and procedures for your entire family, including your pets. Please ask for more information.

Pet Insurance: We also encourage you to consider whether pet insurance is a good choice for your family. With pet insurance, you are responsible for paying the bill at the time of service and your insurance company would reimburse you according to their agreement at a later time.

Refunds: All sales for services rendered are final and not refundable. Sales for dispensed pharmaceuticals are final and not refundable. Sales of prescription veterinary diets are guaranteed by the manufacturer and are always refundable. Sales of non-prescription products may be final and non-refundable, partially refundable, or fully refundable at the discretion of Clearview Animal Hospital.

Fees are due at the time services are rendered. You assume full financial responsibility for all charges incurred by your pet(s).

Please confirm that you have read and understand all above statements (required)

Yes
No

Date (required) :

We will gladly discuss and/or prepare a written estimate of charges for recommended procedures and services. We accept cash, debit cards, VISA, MasterCard, Discover Card, American Express and Care Credit.

Pet Name (required)

Species (required)

Breed (required)

(required)

Male
Male Neutered
Female
Female Spayed

Date of birth or approximate age? (required)

Color & Markings (required)

Microchipped? (required)

Yes
No

Microchip Number (if applicable)

Vaccination history (please check all that apply) (required)
Rabies
Canine Distemper-Parvo Combination (DA2PP)
Leptospira
Bordetella
Canine Influenza
Feline Distemper Combination (FVRCP)
Feline Leukemia
Other

Previous Veterinary Provider (NA if Not Applicable) (required)

Previous Veterinary Phone Number (for records) (required)

Previous Veterinary Provider if more than one (NA if Not Applicable)

Previous Veterinary Phone Number if more than one (for records)

Current Diet (required)

Current Medications (NA if Not Applicable) (required)

Illness/Accidents/Injuries

Surgery/Dentistry

Pet Photo Consent Agreement (choose ONE of the following) (required)

I hereby grant Clearview Animal Hospital permission to use any photographs taken of my pet, in any and all of its publications, including website and social media postings without payment or any other consideration. I understand that my pet will only be identified by name, and no personal information of mine will be released. I understand and agree that these materials will become your property and will not be returned. I hereby authorize to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing your programs or for any other lawful purpose.
I hereby grant Clearview Animal Hospital permission to use any approved photographs taken of my pet, in any and all of its publications, including website and social media postings without payment or any other consideration. I understand that my pet will only be identified by name, and no personal information of mine will be released. I understand that I will approve or reject the use of any photos of my pet, either written or verbally, before exhibition, publication or distribution. I understand and agree that once approved, these materials will become your property and will not be returned. I hereby authorize to exhibit, publish or distribute this photo for purposes of publicizing your programs or for any other lawful purpose. In addition, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby release rights to all claims, demands, and causes to action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of this authorization.
I hereby do not grant permission to Clearview Animal Hospital to use any photographs taken ofmy pet, in any and all of its publications, including website and social media postings.

Please confirm that you have read and understand all above statements (required)

Yes
No

Date (required) :

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