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719-475-1747
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PPVC Online Pharmacy
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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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Pet Health Library
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Contact
New Client Form
Save time and fill out online!
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2
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Client information
Name
*
First
Last
Spouse Name
First
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Date of Birth
*
Month
Day
Year
Social Security Number
*
My pet's appointment is scheduled for:
*
Choose date below
Month
Day
Year
Contact information
Primary Phone Number
*
Cell Phone Number
Employer
Work Phone Number
Spouse's Employer
Spouse's Work 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
Email Reminder Opt-in
*
We email reminders about needed services and appointment reservations. Please make sure to add clientservice@pikespeakvet.com to your email address book.
Yes, I accept.
No, I cannot receive email reminders.
Contact Preference
*
How would you prefer to be contacted regarding follow-up care for your pet(s)?
Phone
Text
Email
We also provide a Pet Portal, a personal website, to each of our patients. Through this portal you will be able to request appointments and prescription refills, upload photos, and more. You must have email to access this service. You will receive an email with a link within 48 hours of your visit. Follow this to set up your pet’s website.
Referral information
How did you learn of our practice?
Please check all that apply.
Outdoor sign
Yellow pages
Online search
Referral from existing/previous client
Which site?
Who can we thank for recommending our practice?
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)
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.
Phone
This field is for validation purposes and should be left unchanged.
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