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719-475-1747
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Call
719-475-1747
for an appointment
PPVC Online Pharmacy
About
About Us
Staff
FAQ
Services
Forms & Resources
Policies & Forms
Pet Health Library
Blog
Contact
Call
719-475-1747
for an appointment
PPVC Online Pharmacy
About
About Us
Staff
FAQ
Services
Forms & Resources
Policies & Forms
Pet Health Library
Blog
Contact
About
About Us
Staff
FAQ
Services
Forms & Resources
Policies & Forms
Pet Health Library
Blog
Contact
PPVC Online Pharmacy
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About
About Us
Staff
FAQ
Services
Forms & Resources
Policies & Forms
Pet Health Library
Blog
Contact
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About
About Us
Staff
FAQ
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Policies & Forms
Pet Health Library
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Contact
Cat/Dog Check-in Form
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Client information
Please fill out one form per patient if you are bringing multiple pets.
Your Name
*
First
Last
My pet's appointment is scheduled for:
*
Choose date below
Month
Day
Year
Pet's Name
*
Phone Number
*
Where can we contact you during your pet's stay with us?
Would you like to receive text message updates at this number?
*
Yes
No
Alternate Phone Number
If we are not able to reach you at the above number, is there another number where we can reach you?
Email Address
*
We use this for invoices, follow-ups, access to our app, appointment confirmations and updates on clinic information.
Enter Email
Confirm Email
How would you prefer to be contacted regarding your pet’s follow-up care?
*
Phone
Text
Email
Pet information
What are we seeing your pet for today? What are your concerns?
*
Please be detailed in explaining unusual behavior.
List any medications including over-the-counter supplements that your pet is currently taking, including name, dose, frequency and last dose given:
*
If none, type "None."
What type of diet is your pet on? Is it grain free? How often and how much are you feeding?
Have your pet's eating habits changed?
Yes
No
Have your pet's drinking habits changed? Have you noticed you are filling the water bowl more than normal?
Yes
No
Have you noticed a change in weight?
Yes
No
Is your pet having diarrhea/loose stools?
*
Yes
No
Does your pet’s urine seem normal, both in amount and/or appearance?
*
Yes
No
Is your pet vomiting, coughing or sneezing?
*
Yes
No
Does your pet have any lumps or bumps that you would like us to check?
*
Yes
No
Does your pet have any mobility issues that are concerning? Seem stiff, sore, or painful anywhere in his/her body?
*
Yes
No
If you had to rate your pet on a scale of 1-4, 1 being bouncing around like a baby kitten/puppy and 4 being lethargic, sleeping a lot, uncomfortable, where would you score your pet on a daily basis?
1
2
3
4
Are your pet's vaccines up to date?
Yes
No
When were vaccines last given? If a new client, did you bring records with you? (If not please indicate where we can call for information.)
Has your pet ever had vaccine reactions before?
Yes
No
Please describe what happens:
Additional requests:
For example: Medication Refills, Microchip, Additional Bloodwork, Nail Trim, Heartworm Prevention, etc.
If you have any photos or videos, please attach them here.
Accepted files types: jpg, gif, png, pdf, mp4, mov. Large files may take longer to upload. Max file size: 64MB.
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, mp4, mov, Max. file size: 64 MB, Max. files: 4.
If your pet is staying with us for a drop-off appointment, please describe any authorized food or medications that you are leaving with us:
Stress-Free Visit
We want to make your pet’s visit as enjoyable and stress-free as possible. As such, it’s important for us to understand what your pet finds upsetting or distressing. This information will help us adjust our care to better serve you and comfort your pet. Please answer these questions to the best of your ability.
Does your pet show any reluctance to get into the car or carrier?
Yes
No
How and where does your pet travel in the car (seatbelt, back, front, loose, carrier)?
During travel to the veterinary clinic, does your pet do any of the following?
Check all that apply
Eager and excited
Subdued
Reluctant
Bark/meow
Hide
Whine
Drool
Pant
Vomit
Tremble
Urinate/BM
Pace
Other...
If other, please describe:
Does your pet prefer:
Female Veterinarian
Male Veterinarian
No preference
Check any situations listed below that your pet has shown avoidance to or dislike of in the past. You can add comments at the end.
Getting in their carrier or the car
Entering the veterinary clinic
Other pets and/or people passing by while in reception/check-in
Waiting with other people in the waiting area
Being approached by veterinary staff
Getting on the scale for a weight
Hearing the doorbell, overhead intercom or phones ringing
Sounds coming from the back area of the practice
Going into the exam room
Being put on the table for an examination
Having direct eye contact with the veterinarian and/or staff
Loud voices during examination
Having a rectal temperature taken
The use of instruments such as a stethoscope or otoscope (to look in ears)
Being taken out of exam room for procedures
Additional comments:
How would you describe your pet around other animals and people?
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
Social Media Consent
*
I hereby give Pikes Peak Veterinary Clinic (PPVC) permission to take photographs and videos of me and my pet for the purpose of posting on PPVC's Facebook, YouTube, Twitter, clinic website and other social media outlets. I hereby release and discharge PPVC from any and all claims arising out of the use of the photos. PPVC has my permission to use (check one of the following):
Only my pet’s name(s)
My pet’s name(s) and my first name
My pet’s name(s) and my first and last name
I do not consent to photos or videos for PPVC's social media.
Consent and Privacy Agreement
*
CONSENT
By clicking the checkbox below I am providing my consent to the terms described below.
I hereby authorize the Pikes Peak Veterinary Clinic (PPVC) veterinarian to examine, prescribe for, or treat the above described pet.
As the owner or agent of the above animal, I hereby give my consent to PPVC to perform a physical exam. Additional treatments and procedures will be communicated in person (or via phone when lab results are returned) and will be noted in my pet's medical record as confirmed or declined.
I understand that during the performance of these procedures unforeseen circumstances may be revealed that necessitate an extension or variance in the procedures set forth. I expect PPVC to use reasonable care and judgment in performing the procedures. The nature of the procedures and the risks have been explained to me and I realize results cannot be guaranteed.
I am also aware that unforeseen events resulting from the procedure will not relieve me from any obligation to pay all reasonable costs incurred regarding the animal.
(Please know that our attention is placed on you and your pet while your pet is 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.)
I understand that payment is required in full at the time services are rendered.
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 terms.
Comments
This field is for validation purposes and should be left unchanged.
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