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Patient Registration
First Name
Last Name
Secondary First Name
Secondary Last Name
Home Address
City
State
Zip Code
Are you 65 or over?
select
yes
no
Email Address
Phone Number
Phone Type
Please Select
Home
Cell
Work
Secondary Phone Number
Phone Type
Please Select
Cell
Home
Work
Patient Name
Species
Please Select
Canine
Feline
Sex
Please select
Intact Female
Intact Male
Spayed Female
Neutered Male
Breed
Age/Date of Birth
Color
Is this a registered service animal?
no
yes
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.
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