New Client Form

Joint ownership

(If applicable)

Is this pet jointly owned by someone other than you and your spouse?*

Yes
No

Name of 1st Joint Owner*

First Last

Address of 1st Joint Owner*

Street Address City State / Province / Region ZIP / Postal Code

Phone Number of 1st Joint Owner*

Name of 2nd Joint Owner

First Last

Address of 2nd Joint Owner

Street Address City State / Province / Region ZIP / Postal Code

Phone Number of 2nd Joint Owner

Percentage of Ownership*

Describe the percentage of ownership for each person:

Primary Responsibility*

Designate one person to be primarily responsible for final decisions on care. IMPORTANT: Payment in full is required at the time of service regardless of who brings in the pet(s).

Other authorized person(s)

Other Authorized Person(s)

If applicable, please list any other person(s) with whom you authorize us to share your personal information and information about your pet(s) (mother, daughter, pet-sitter, etc.):

Address of Authorized Person(s)

Street Address City State / Province / Region ZIP / Postal Code

Phone Number of Authorized Person(s)

Cell Phone Number of Authorized Person(s)

Email of Authorized Person(s)

CPR/DNR consent

CPR/DNR*

In the event that your pet(s) should experience cardiac or respiratory arrest while being hospitalized at Pikes Peak Veterinary Clinic, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet’s status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Please select your choice below.

I agree to CPR being performed in case of arrest (Starting fees of $300-$500)
I elect a “Do Not Resuscitate” status in case of arrest

Social media consent

Social media release*

I hereby give Pikes Peak Veterinary Clinic permission to take photographs and videos of me and my pet for the purpose of posting on Pike’s Peak Veterinary Clinic’s Facebook, YouTube, TikTock, X, clinic website and other social media outlets. I hereby release and discharge Pikes Peak Veterinary Clinic from any and all claims arising out of the use of the photos. Pikes Peak Veterinary Clinic has my permission to use: (select one)

Only my pet’s name(s)
My pet’s name(s) and my last name
My pet’s name(s) and my first and last name
I do not authorize permission for PPVC to use my or my pet’s photographs or videos.

I give authorization to use my pet’s name as entered below:*

I give authorization to use my name as entered below:*

Client consent

Consent & privacy agreement*

Consent
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume full responsibility for all charges incurred in the care of this animal. I also understand that the full amount must be paid before my pet can be released to me, and that a deposit may be required for surgical procedures.

Please know that our attention is placed on you and your pet while you are at Pikes Peak Veterinary Clinic. Occasionally we may miss charges and you are authorizing that we may bill you for any missed charges found within 30 days of your appointment.

Privacy
We are the sole owners of the information collected on this site. We only have access to and/or collect information that you voluntarily give us via direct contact from you. We will not sell or rent this information to anyone.

We will use your information to respond to you regarding the reason you contacted us. We will not share your information with any third party outside of our organization other than as necessary to fulfill your request, e.g. to fulfill an order.

Unless you ask us not to, we may contact you in the future to tell you about specials, new products or services, or changes to this privacy policy.

If you feel that we are not abiding by this privacy policy, you should contact us immediately.

I agree to the consent terms and privacy policy.

Client signature*

By entering my name below, I affirm that the information I have given is accurate to the best of my knowledge, and I give or refuse my consent as indicated in this form.

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Client information

Contact information

Referral information

Joint ownership

Other authorized person(s)

CPR/DNR consent

Social media consent

Client consent

Monday	7:30 a.m. – 5:30 p.m.
Tuesday	7:30 a.m. – 7:00 p.m.
Wednesday	7:30 a.m. – 5:30 p.m.
Thursday	7:30 a.m. – 5:30 p.m.
Friday	7:30 a.m. – 5:30 p.m.
Saturday	8:00 a.m. – 12:00 p.m.
Sunday	CLOSED