Online Signup in Colorado Springs, CO | Bear Creek Veterinary Care

Name*

First Last

Spouse Name

First Last

Preferred Main Contact*

Preferred Phone Number*

Additional Phone Numbers

Landline	Cell	Work

Email*

Second Email

Referal Source*

Whom may we thank?

Prefered Communication Method*

Text
Email
Phone

Employer

Spouse Employer

Pet Information

Pet's Name*

Color*

How long have you had your pet?*

What brand of food does he/she eat?*

Please list any past veterinarian(s) where records can be requested

Name	Phone Number	Email

Is your pet currently on medications?*

Yes
No

Please list any medications*

I grant Bear Creek Veterinary Care, its representatives and employees the right to electrnically publish and to use my pet's photographs, story and medical information on digital sign, website and social media!*

I consent
I do not consent

Consent*

I hereby authorize the veterinarian to examine, prescribe for, and treat my pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that a deposit may be requried for hospitalization and/or treatment, that all professional fees are due at time services are renered, and I agree to pay for these services. I understand that there is a minimum of $20 service charge for all returned checks. Any unpaid account more than 30 days past due will be sent to a collection agency.

Digital signature of owner*

Date*

Digital signature of co-owner

Date

Next step will take you to Rapport, our communication portal for your pet. There you will fill out name, address and more information about your pet that is linked directly into our office software. Final step is to set your first appointment online.

Please select an appointment. If none of the times offered works for you please select one, put a note in the comment window for us to call you and we will find an appointment time that works for you.Please fill out as many fields as applicable. Thank you for choosing Bear Creek Veterinary Care!