Hospital Owner Information Form Prescription Refill Request International Health Certificate (IHC) Agreement Veterinary Services Agreement Boarding & Daycare Boarding and Daycare Agreement Holiday Boarding Agreement Owner Information Form Please enable JavaScript in your browser to complete this form.Owner Name *FirstLastSpouse / OtherFirstLastPrimary Phone Number *Phone Type *CellHomeWorkOtherAdditional Phone NumberPhone TypeCellHomeWorkOtherEmail Address: *Appointment reminders are sent by email.* *Mailing Address *City *State *Zip Code *Pet's Name *Pet's Age (Years, Months) *Type of Pet *CanineFelineAviaryExoticOtherBreed *Color, Markings *Sex *MaleFemaleIs your pet neutered/spayed? *NeuteredSpayedIntactAre your pet's vaccines current? *YesNoDo you have your pet's medical record? *YesNoIs your pet's medical record at another veterinary practice? *YesNoName of Former Veterinary Practice *Would you like us to request a transfer of your pet's medical record for you? *YesNoDoes your pet have a specific condition that prompted your interest in our hospital? *Would you like us to contact you to schedule an appointment? *YesNoAre there any special requests that you have for your pet's visit?Please list any additional pets here.How did you hear about us?Personal ReferralHospital ReferralHospital SignGoogleYelpOtherName of Referral (If Applicable)Today's Date *Signature *Clear SignatureBy signing in the box above, 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.PhoneSubmit Prescription Refill Request Please enable JavaScript in your browser to complete this form.Owner Name *FirstLastMailing Address *City *State *Zip Code *Best Phone Number *Additional Phone NumberEmail *Pet's Name *Sex *MaleFemaleAge: Year, MonthsMedication Requested *Additional Comments / QuestionsCommentSubmit International Health Certificate (IHC) Agreement Please enable JavaScript in your browser to complete this form.Client Full Name *agrees to the following International Health Certificate (IHC) guidelines set by Longs Peak Animal Hospital (LPAH): For the purposes of this agreement, the IHC process includes certification for travel to destinations outside of the US and the state of Hawaii. Client understands the following: To begin the IHC process a deposit of $167.25 must be made (for Document Review and International Health Certificate Consult), the "Pet Owner Worksheet" must be completed and returned, as well as all previous veterinary records and supporting documentation must be submitted to LPAH. The Document Review ($79.25) is a non-refundable deposit. The International Health Certificate Consult ($88.00) is refundable up to 48 hours prior to the scheduled consultation. If the certification process needs to be canceled for any reason within the 48 hours prior to the scheduled consultation the entire deposit ($167.25) will not be refunded. If the process of the IHC needs to be canceled during any point of the process the owner will not be refunded for any services already completed during the process. Once the "IHC Agreement" and "Pet Owner Worksheet" has been filled out and submitted to LPAH via email at [email protected] or a physical copy has been dropped off, the hospital staff will reach out to schedule the consultation and collect the deposit. Signature *Clear SignatureSubmit Veterinary Services Agreement Please enable JavaScript in your browser to complete this form.Client First and Last Name *GENERAL TERMS: Charges are due and payable at the time of service, regardless of who brings the patient for treatment, unless other arrangements are made in advance. It is the client’s responsibility to ensure that all contact information on file is kept up-to-date. This requires notification of changes in name, address, telephone numbers, and email address. An updated Owner Information Form is required every 12 months. An estimate of charges will be provided for any case where in-hospital treatment, surgery, or hospitalization is recommended. A deposit prior to treatment may be required. Any unpaid balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5%. Any balance left unpaid for three months will be forwarded to a collection agency and will incur a 25% collection fee for which the client is liable, in addition to monthly finance charges. All invoices are reviewed for accuracy. Additional charges or credits may be due. APPOINTMENT CANCELLATION: To keep appointments available for other clients, LPAH requires a 24-hour notice of cancellation. The courtesy of your phone call allows us to schedule other patients in need of care. If we are closed, please leave a voicemail. Unless cancelled at least 24 hours in advance, a charge for each missed appointment will be due at the time of scheduling your next visit. If a 24-hour notice is not possible, we ask that you notify us as soon as you are aware of the need to cancel or reschedule the appointment. PAYMENT FOR SERVICES: LPAH accepts cash, Visa, MasterCard, Discover, American Express, CareCredit, and Scratch Financing. (If requested, Credit/Debit Card information can be securely stored for future use). CareCredit We do not process CareCredit payments less than $100. According to CareCredit policies, we cannot process CareCredit transactions over the phone. The cardholder or an authorized user must be present at time of payment. The cardholder must inform CareCredit of any authorized users in advance of payment. The cardholder or authorized user must always provide a primary form of ID (usually a driver’s license). A second form of ID is required if the CareCredit card is not present; a credit card suffices for this purpose. Scratch Financing All terms of a client’s Scratch Financing agreement will be set by Scratch Pay. Longs Peak Animal Hospital can only process payments through Scratch Pay that are at or below the clients financed amount. Terms of service are set by Scratch Pay and clients may not qualify for any/all plans offered by Scratch Pay. Longs Peak Animal Hospital has no say in the amount a client is approved for. The authorized user must always provide a primary form of ID (usually a driver’s license) when processing a Scratch Pay transaction. Applications must be submitted online by the client at scratchpay.com/consumer. ONLINE PHARMACIES: LPAH does not communicate directly with online pharmacies and the client is responsible for submitting a written prescription if they choose to purchase medications through an online pharmacy. If a written prescription is requested for use with an online pharmacy, LPAH cannot guarantee that the accurate medication is filled or the quality of the product. The client is responsible for asking LPAH for written prescriptions ahead of time for any refills needed. ACKNOWLEDGEMENT: I accept the full financial responsibility for all services provided by LPAH for any of the pets listed on my account. I have read and understand the above statements and will adhere to the terms of this agreement.Signature *Clear SignatureSubmit Boarding and Daycare Agreement Please enable JavaScript in your browser to complete this form.Owner Name *FirstLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Spouse/OtherMailing Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBest Phone Number *Additional Phone NumberEmail *Pet #1 - Name *Breed *Color *Age *Canine or Feline? *CanineFelineMale or Female? *MaleFemaleIs Your Pet Spayed/Neutered? *Spayed/NeuteredNot Spayed/NeuteredPhysical AnomaliesAdd An Additional PetPet #2 - NameBreedColorAgeCanine or Feline?CanineFelineMale or Female?MaleFemaleIs Your Pet Spayed/Neutered?Spayed/NeuteredNot Spayed/NeuteredPhysical AnomaliesAdd An Additional PetPet #3 - NameBreedColorAgeCanine or Feline?CanineFelineMale or Female?MaleFemaleIs Your Pet Spayed/Neutered?Spayed/NeuteredNot Spayed/NeuteredPhysical AnomaliesAdd An Additional PetPet #4 - NameBreedColorAgeCanine or Feline?CanineFelineMale or Female?MaleFemaleIs Your Pet Spayed/Neutered?Spayed/NeuteredNot Spayed/NeuteredPhysical AnomaliesGENERAL TERMS: A. Longs Peak Animal Hospital (LPAH) is receiving the animal(s) above described for the purpose of Boarding, Daycare or any other service ordered by Owner or Owner’s agent, at the expense of and for the account of Owner. Owner agrees to pay the sum as specified for all chosen services. B. Owner shall pay all costs and charges of and for special services, and all veterinary and medical costs that may be incurred during the time LPAH is responsible for the care of the animal(s) above described. C. Owner recognizes that LPAH may require a non-refundable deposit on bookings or full payment in advance. D. Owner agrees that LPAH will not be responsible for the destruction or loss of any toys, leashes, collars, bedding or any other property left with the animal. Pet's Regular Veterinarian *Veterinarian Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeVeterinarian Phone *Emergency Contact/Phone *VACCINATION POLICY: A. Owner represents that prior to acceptance of the animal by LPAH, Owner will provide a copy of current vaccination records and a current “kennel cough” or Bordetella vaccination for animal, stating that all vaccinations are up to date for the entire stay at the kennel. B. To ensure the protection of all pets under our care, including your own, the following must be up to date: DOGS: Rabies, DHPPC & Bordetella CATS: Rabies & FVRCP C. If not up to date, or if unable to provide proof of vaccination, I give permission to update my pet(s) vaccinations in accordance with the policies of LPAH. If any fleas/ticks are observed on your pet(s) while boarding, he/she (they) will receive a flea bath/dip at the owner’s expense. LIABILITY: A. LPAH shall not be liable for any damages to the animal arising out of or from the boarding or keeping of the animal or that may accrue from any cause in connection with such boarding, including loss by fire, theft, running away, death, or injury during the term of this agreement, whether the animal is on the premises of LPAH or not, except where any such loss is caused by the neglect or intentional act of LPAH or by any of LPAH’s agents or employees. In the unlikely event of death, no final course of action will be taken without consent of the owner. However, Owner shall be solely responsible for all costs associated with disposition of a body. B. In no case shall LPAH be liable for the animal’s acts and behavior, other than for the exercise of gross negligence on the part of LPAH, its agents or employees, in the boarding or keeping of the animal. Owner shall indemnify LPAH from and against any and all damages sustained or suffered by reason of the boarding or keeping of the animal for any claims or injuries arising out of the boarding and keeping of the animal. LIEN FOR CHARGES: A. LPAH shall have a lien on the animal for all unpaid boarding and other charges resulting from the boarding or keeping of the animal under this agreement. B. Payment for services pursuant to this agreement is due and payable on the day of delivery of animal to Owner. Owner agrees that in the event the specified boarding charges are not paid when due and payable, in accordance with the terms of this agreement, LPAH may exercise its lien rights, and in connection with such rights, may dispose of the animal for any and all unpaid charges, at private or public sale, after 10 days’ notice to Owner of such unpaid charges. In the event such sale does not secure a sufficient price to pay the costs of board and other charges, plus costs of sale, owner shall pay to LPAH the difference. ILLNESS OF PET: One of the advantages of boarding your pet(s) at a veterinary clinic or hospital is that veterinary attention is readily available should the need arise. In the event your animal becomes ill, every attempt will be made to contact Owner at the phone number(s) listed in this agreement. If Owner does not immediately inform LPAH regarding measures to be taken or if the animal’s health requires emergency action, the right to provide medical treatment within LPAH’s discretion is granted to LPAH, and Owner shall promptly pay any expenses incurred in connection with such care. DAYCARE: All dogs enrolled in LPAH Daycare will be engaging in social play with other dogs. LPAH will supervise playtimes and will use reasonable care to ensure that injuries do not occur. Owner agrees that in the event that an injury does occur, all veterinary charges required to properly treat the animal for such injury are the sole responsibility of the Owner. PAYMENT FOR SERVICES: Charges are due and payable at the time of service, unless other arrangements are made in advance. Unscheduled or late pick-ups may result in additional fees. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance left unpaid will be forwarded to a collection agency, and will incur a 25% collection fee for which Owner is liable, in addition to monthly finance charges. A signature indicates that you have read and agree to the above information regarding your animal(s) while under the care of LPAH: PHOTOGRAPH/MEDIA RELEASE: *I allowI do not allowLPAH to use my pet’s likeness in a photograph or video in any and all of its publications, including website entries and social media, without payment or any other consideration. I understand that these materials will become the property of LPAH and will not be returned. I also authorize LPAH to edit, alter, copy, exhibit, publish or distribute this photograph or video for purposes of publicizing its services, and I waive the right to approve the finished product where my pet’s likeness appears. Today's Date *Signature *Clear SignatureBy signing in the box above, you indicate that you have read and agree to the above information regarding your animal(s) while under the care of LPAH: WebsiteSubmit Holiday Boarding Agreement Please enable JavaScript in your browser to complete this form.For the purposes of this agreement, “Holiday Periods” are defined as any boarding stay that includes one or more of the following national holidays: New Year’s Day Easter Memorial Day 4th of July Labor Day Thanksgiving Day Christmas Day Owner understands that if the boarding stay takes place over a Holiday Period, the reservation must be prepaid in full when the reservation is made. Owner understands that if the entire Holiday Period reservation is canceled with less than two weeks of notice, Owner forfeits the reservation prepayment, including all fees paid for Daycare, a One-on-One, or any other boarding stay upgrade defined in the original reservation. Owner understands that if only a portion of the Holiday Period reservation is canceled with less than two weeks of notice (late check-in, early check-out, etc.), Owner will not be refunded for the unused days of the reservation or for any special fees paid to include Daycare, a One-on-One, or any other boarding stay upgrade defined in the original reservation. Owner understands that there is no check-in or check-out available on any of the national holidays listed above. On these days, the LPAH Boarding and Daycare department is only staffed to provide care for the boarding animals and is not staffed for administrative purposes.Owner Name *FirstLastToday's Date *Signature *Clear SignatureBy signing in the box above, you indicate that you have read and agree to the above information about special procedures during the holidays:WebsiteSubmit
