*Name(s):

*Address:

*City, State, Zip Code:

*Home Phone:

Work Phone:

Cell Phone:

*Pet's Name:

*Species:

Breed:

Age:

*Sex:

*Altered:

Previous/Current Health Concerns:

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

Who is your pet's regular veterinarian?

Pet's Name:

Species:

Breed:

Age:

Sex:

Altered:

Previous/Current Health Concerns:

Is your pet on any medications (please list all)?:

Who is your pet's regular veterinarian?:

To allow for optimal treatment of your pet(s), all patients hospitalized at Aspen Meadow Veterinary Specialists/Animal Emergency & Critical Care are assigned a CPR code. This code enables AMVS to carry out your wishes if it becomes necessary during or following an emergency.

*CPR/DNR Code

No, Do Not Resuscitate (DNR)
Yes, Please Administer CPR

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, I hereby authorize Aspen Meadow Veterinary Specialists, PC (AMVS)/Animal Emergency & Critical Care,LLC (AECC) 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 $300-$600. I understand that further testing may be necessary. A thorough exam will be performed by the staff veterinarian. Once you are reached by telephone, you and the veterinarian will create a comprehensive treatment plan for your pet, and an estimate will be prepared. You will be responsible for any charges incurred at the time of service.

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 303.678.8844 if you would like to schedule a tour at your convenience.