Pre-Registration Form - Alpenglow Veterinary Specialty + Emergency Center

If you are a human and are seeing this field, please leave it blank.

Fields marked with a * are required

Which office are you visiting:

Aspen Meadow - Surgery or Internal Medicine
Rocky Mtn. Vet Cardiology
Emergency Transfer

Date of appointment:

Client Information

Your Name(s): *

Street Address: *

City: *

Zip Code: *

Best Phone: *

Work Phone:

Cell Phone:

Email Adress:

*Your email address will never be shared with any 3rd parties.

Pet Information

Pet's Name: *

Breed:

Age:

Birthday (if known):

Previous/Current Health Concerns, including Allergies:

Is your pet on any medications (please list all and their doses)?

Who is your pet's regular veterinarian?

Additional Pet Information

CPR (Cardiopulmonary Resuscitation)/DNR (Do Not Resuscitate)

To allow for optimal treatment of your pet(s), all patients hospitalized at Alpenglow Veterinary Specialty + Emergency Center are assigned a CPR code. This code enables AVSEC to carry out your wishes if it becomes necessary during or following an emergency.

If it becomes necessary during your pet's visit/stay, would you like us to administer CPR?

Please note, we will attempt to contact you immediately for further instruction and discussion of your pet's condition if CPR is initiated.

Financial Information (optional):

Please provide any financial information you feel is necessary to address concerns during your pet's visit/stay:

In the event that I am unreachable by phone, I hereby authorize Alpenglow Veterinary Specialty + Emergency Center (AVSEC) to do what is necessary to stabilize my pet in an emergency situation.

These measures may include (but are not limited to): Radiographs (X-rays), laboratory testing, and injection or pain medication administrations. These initial diagnostic/treatment measures may cost $400-$600. I understand that further testing may be necessary.

A thorough exam will be performed by the staff veterinarian. Once I am reached by telephone, myself and the veterinarian will create a comprehensive treatment plan for your pet, and an estimate will be prepared. I understand I will be responsible for any charges incurred at the time of service.

Authorized Signature:

Additional Notes/Requests/Comments about your Pet's Stay and/or Special Needs:

We are happy to provide a tour of our facility and look forward to working with you and your pet! Please call 303.443.GLOW (4569) if you would like to schedule a tour at your convenience.

Are you human? Then type in 25xba. *