Longs Peak Animal Hospital

9727 Ute Highway
Longmont, CO 80504

(303)776-6666

longspeakah.com

New Client Check-In

If you would like to make an appointment, you can assist us in expediting your check-in by submitting this form.


New Client

Owner's Name (required)
First Name (required)
Last Name (required)
Date of Birth
Date (required) :
Spouse/Other
First Name
Last Name
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Mailing Address (if different)
Street Address
City
,
State / Province
Zip / Postal Code
Primary Phone (required)
Phone TypePhone Number (required)
Additional Phone (required)
Phone TypePhone Number (required)
E-mail
E-Mail Address (required) :
Do you prefer email reminders?
Yes
No


Employment Information (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Employer Phone (required)
Phone TypePhone Number (required)
Pet's Name (required)
First Name (required)
Last Name (required)
Age: Years, Months

Type of Pet (required) :
Breed:

Color/Markings:

Sex: (required)
Male
Female



Neutered
Spayed
Intact


Medical History
Are your pet's vaccines current?
Yes
No


Do you have your pet's medical record?
Yes
No


Is your pet's medical record at another veterinary practice?
Yes
No


Name of Former Veterinary Practice

Would you like us to request a transfer of your pet's medical record for you?
Yes
No


Your First Visit
Does your pet have a specific condition that prompted your interest in our hospital?

Would you like us to contact you to schedule an appointment? (required)
Yes
No


Are there any special requests that you have for your pet's visit?

Additional Pets
Please list any additional pets here.

Referrals
How Did You Hear About Us? :
Name of Individual or Hospital:

Terms and Conditions
Acknowledgement & Authorization: (required)
I certify that the information given herein is true and complete to the best of my knowledge. Individuals listed on this form will be authorized to make medical decisions regarding all patients associated with this account.

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