Client Intake Form RiNoVet Animal Emergency Care 4495 Washington Street, Denver, Co 80216 303-458-5555 Client Name * First Last Spouse/Secondary Name First Last Phone * Secondary Phone Home Address * Address, City, State, Zip Email Address * How did you hear about us? Pet Name * Age/DOB * Select Feline Canine Breed and Coloring Select Spayed Female Intact Female Neutered Male Intact Male Primary Veterinary Clinic (specify location for Banfield or Thrive): * In the event that your pet has a cardiac or respiratory arrest, do you authorize RiNoVet Animal Emergency Care to perform CPR? You acknowledge that there are costs associated with CPR and you are responsible for all costs incurred. * CPR DNR Confirm above * CPR DNR By signing (typing name) below, you certify that you are over the age of 18 and are the owner (or authorized agent) of the above-described patient. You authorize RiNoVet Animal Emergency Care personnel to treat your pet. You understand that you are not guaranteed a successful outcome and you shall not hold the hospital (or its affiliates, employees, agents or contractors) liable for procedures performed and recovery of your pet. You understand that if your pet must be hospitalized, a deposit of the low end of your estimate must be made prior to treatments. Full payment for services rendered will be required prior to the discharge of your pet. You understand you are responsible for all costs incurred and if it becomes necessary to pursue legal action to recover the balance due, you agree to pay all collection, attorney and court fees associated in addition to a service fee. Typed Signature *
