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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 Us
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Existing Client Information Update Form
Save time and fill out online!
Client information
Name
*
First
Last
Spouse Name
First
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Primary Phone Number
*
Cell Phone Number
Spouse's Primary Phone Number
Spouse's Cell Phone Number
Email Address
*
Which email address would you prefer to use for reminders about your pet's care?
Enter Email
Confirm Email
Contact Preference
*
How would you prefer to be contacted regarding follow-up care for your pet(s)?
Phone
Text
Email
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?
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.
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.
Comments
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