Patient Registration

First Name

Last Name

Secondary First Name

Secondary Last Name

Home Address

City

State

Zip Code

Email Address

Phone Number

Phone Type

Secondary Phone Number

Phone Type

Patient Name

Species

Sex

Breed

Age/Date of Birth

Color

Is this a registered service animal?

Registration Number

Primary Veterinarian and Hospital Name (where you go for vaccines and check ups)

City

Other Veterinarian (specialists or emergency hospitals)

City

Consent to Treat

I, the undersigned, being 18 years of age or older, am the owner or agent of the owner of the animal(s) described above and am authorized to make decisions regarding its care. I hereby consent to the examination of my pet by the staff at Boulder Road Veterinary Specialists. I agree to assume financial responsibility for the exam fees at the time my pet is discharged from the hospital. I understand that good faith estimates for fees related to further care will be discussed before services are rendered.

Media Consent

I hereby grant permission to Boulder Road Veterinary Specialists to use photographs and/or video of my pet and myself, in publication, news releases, online, social media and in other communications related to the mission of Boulder Road Veterinary Specialists.

Are you 65 or over?

Document Upload (PDF only)

Is there anything else we need to know?