Contact Name *
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Contact Email Address *
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Contact Address *
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Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Contact Phone Number *
(Required)
How did you hear of us? *
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Pet Name *
(Required)
Pet Species
AVIAN
BOVINE
CANINE
CAPRINE
CASH LARGE
CASH SMALL
EQUINE
FELINE
LAGOMORPHA
MUSTELIDAE
OTHER LARGE
OTHER SMALL
OVINE
OTHER SPECIES
PORCINE
PROCYONIDAE
REPTILIA
RODENTIA
UNKNOWN
Species: AVIAN | Breed:
(Required)
AFRICAN GREY
AMAZON
BUDGERIGAR
CAIQUE
CANARY
COCKATIEL
COCKATOO
CONURE
DUCK
ECLECTUS
FINCH
GRASS PARAKEET
INDIAN RING NECK
LORIKEET
LORY
LOVEBIRD
MACAW
MYNAH
OTHER BREED
PARAKEET
PARROT
PIONUS
POULTRY
QUAKER PARAKEET
ROSELLA
WILD BIRD
UNKNOWN
Species: BOVINE | Breed:
(Required)
ABERDEEN-ANGUS
ANCHINA
ANGUS
ANKOLE
AYRSHIRE
BEEF MIXED
BEEFMASTER
BRAFORD
BRAHMAN
BRANGUS
BROWN SWISS
CHARBRAY
CHAROLAIS
CHIANINE
CROSSBRED
DAIRY MIXED
DEVON
DUTCH BELTED
GALLOWAY
GELBVIEH
GUERNSEY
HEREFORD
HIGHLAND
HOLSTEIN-FRIESIAN
HOLSTEIN
JERSEY
LIMOUSIN
LONGHORN
MAINE-ANJOU
POLLED HEREFORD
POLLED SHORTHORN
RED ANGUS
RED DANISH
RED POLL
SANTA GERTRUDIS
SCOTCH HIGHLAND
SHORTHORN
SIMBRAH
SIMMENTAL
SOUTH DEVON
OTHER BREED
UNKNOWN
Species: CANINE | Breed:
(Required)
AFFENPINSCHER
AFGHAN (HOUND)
AFGHAN MIX
AIREDALE (TERRIER)
AIREDALE TERRIER MIX
AKBASH
AKITA
ALASKAN MALAMUTE
AMER STANFFOR. TERR.
AMERICAN BULLDOG
AMERICAN BULLY
AMERICAN ESKIMO
AMERICAN FOXHOUND
AMERICAN SPITZ
AMERICAN STANFFORD TERRIER
AMERICAN WATER SPAN.
ARCTIC HUSKY
AUSTRALIAN (TERRIER)
AUSTRALIAN BLUE HEAL
AUSTRALIAN CATTLE DOG
AUSTRALIAN KELPIE
AUTRALIAN SHEPHERD
ALASKAN KLEE KAI
BARDINO
BASENJI
BASSETT HOUND
BASSETT MIX
BEAGLE MIX
BEAGLE
BEARDED COLLIE
BEDLINGTON (TERRIER)
BELGIAN MALINOIS
BELGIAN SHEEPDOG
BELGIAN TERVUREN
BERNESE MOUNTAIN DOG MIX
BERNESE MOUNTAIN DOG
BICHON FRISE
BLACK-TAN COONHOUND
BLOODHOUND
BLUE HEELER
BORDER (TERRIER)
BORDER COLLIE MIX
BORDER COLLIE
BORZOI
BOSTON (TERRIER)
BOUVIER DES FLANDRES
BOXER MIX
BOXER
BOYKIN SPANIEL
BOYKIN
BRIARD
BRITTANY SPANIEL
BRUSSELLS GRIFFON
BULL (TERRIER)
BULLDOG
BULLMASTIFF MIX
CAIRN (TERRIER)
CANE CORSO
CARDIGAN WELSH CORGI
CATAHOULA LEOPARD DG
CATALONIAN SHEEPDOG
CAV. KING CHAS. SPAN
CHESAPEAKE BAY RETR.
CHIHUAHUA MIX
CHIHUAHUA
CHINESE CRESTED DOG
CHOW CHOW MIX
CHOW CHOW, SMOOTH
CHOW CHOW
CLUMBER SPANIEL
COCKAPOO
COCKER (SPANIEL)
COCKER SPANIEL MIX
COLLIE MIX
COLLIE
COON HOUND
COTON DE TULEAR
CURLY COATED RETR.
CAVAPOO
DACHSHUND MIX
DACHSHUND POODLE MIX
DACHSHUND
DALMATIAN MIX
DALMATIAN
DANDIE DINMONT TERR.
DOBERMAN (PINSCHER)
DOBERMAN MIX
DOGO ARGENTINO
DOODLE
DRENTSE PARTIJSHOND
DUTCH WATER SPANIEL
ENGLISH BULLDOG
ENGLISH COCKER SPAN.
ENGLISH COONHOUND
ENGLISH FOXHOUND
ENGLISH POINTER
ENGLISH SETTER
ENGLISH SHEPHERD
ENGLISH SPRINGER SPA
ENGLISH TOY SPANIEL
ENGLISH TOY TERRIER
ENTELBUCHER MOUNTAIN DOG
FIELD SPANIEL
FLAT COATED RETRIV.
FOXHOUND
FRENCH BULLDOG
GER SHORTHAIRED POIN
GER WIREHAIRED POINT
GERMAN SHEPHERD MIX
GERMAN SHEPHERD
GIAN SCHANAUZER
GOLDER RETRIEVER MIX
GOLDEN RETRIEVER
GOLDENDOOGLE
GORDON SETTER
GREAT DANE MIX
GREAT DANE
GREAT PYRENEES
GREYHOUND
GREATER SWISS MOUNTAIN DOG
HARRIER
HAVANESE
HOUND DOG MIX
IBIZAN HOUND
IRISH (TERRIER)
IRISH SETTER MIX
IRISH SETTER
IRISH WATER SPANIEL
IRISH WOLFHOUND MIX
IRISH WOLFHOUND
ITALIAN GREYHOUND
JACK RUSSELL TERR
JAPANESE CHIN
JAPANESE SPANIEL
JINDO
KEESHOND MIX
KEESHOND
KERRY BLUE TERRIER
KING CHARLES SPANIEL
KOMONDOR
KUVASZ
LABRADOR RETR. MIX
LABRADOR RETRIEVER
LAKELAND (TERRIER)
LG-HAIRED CHIHUAHUA
LG-HAIRED DACHSHUND
LHASA APSO MIX
LHASA APSO
LOWCHEN
LLEVELLIN SETTER
MALTESE MIX
MALTESE
MANCHESTER (TERRIER)
MASTIFF
MINATURE BULL TERR.
MINATURE DACHSHUND
MINATURE PINSCHER
MINATURE POODLE
MINATURE SCHNAUZER
MINI BERNEDOODLE
MIXED (BREED)
MOUNTAIN FEIST
MINI AUSSIE DOODLE
NEAPOLITAN MASTIFF
NEWFOUNDLAND
NORFOLD (TERRIER)
NEAPOL MASTIFF MIX
OLD ENG SHEEPDOG MIX
OLD ENGLISH BULLDOG
OLD ENGLISH SHEEPDOG
OTTER HOUND
PAPILLON
PARTY POODLE
PEKAPOO
PEKINGESE MIX
PEKINGESE
PEMBROKE WELSH CORGI
PETIT BASSET GRIFFON
PHARAOH HOUND
PIT BULL
PITBULL
PLOTT HOUND
POINTER MIX
POINTER
POL OWCZAREK NIZINNY
POMERANIAN MIX
POMERANIAN
POODLE MIX
POODLE
PORTUGUESE WATER DOG
PRESA CANARIO
PUG
PULI
PYRENEAN SHEPHERD
RAT TERRIER
REDBONE COONHOUND
REDBONE
RHODESIAN RIDGEBACK
ROTTWEILER MIX
ROTTWEILER
RUSSIAN SHEPHERD
RUSSIAN SULKA
RUSSIAN WOLFHOUND
SAINT BERNARD MIX
SAINT BERNARD
SALUKI
SAMOYED
SCHIPPERKE
SCHNAUZER MIX
SCOTCH COLLIE
SCOTTISH (TERRIER)
SCOTTISH DEERHOUND
SEALYHAM (TERRIER)
SFT COAT WHEATEN TER
SHAR PEI
SHEPHERD
SHETL. SHEEPDOG MIX
SHETLAND SHEEPDOG
SHIBA INU
SHIH TZU MIX
SHIH TZU
SIBERIAN HUSKY MIX
SIBERIAN HUSKY
SILKY (TERRIER)
SILKY (TERRIER) MIX
SKYE (TERRIER)
SMOOTH-COAT COLLIE
SMOOTHHAIRED FOX TER
SPITZ MIX
SPRINGER SPANIEL MIX
SPRINGER SPANIEL
STANFFORD. BULL TERR
STANDARD POODLE
STANDAR SCHNAUZER
SUSSEX SPANIEL
SPANISH MASTIFF
TERRIER MIX
TERRIER
TERRIPOO
TIBETAN (TERRIER)
TIBETAN SPANIEL
TIBETIAN MASTIFF
TOY FOX TERRIER
TOY MANCHESTER TERR
TOY POODLE
TREEING WALKER CNHND
VIZSCLA
WALKER HOUND
WEIMARANER MIX
WEIMARANER
WELSH (TERRIER)
WELSH CORGI MIX
WELSH CORGI
WELSH SPRINGER SPAN
WEST HIGHLAND MIX
WEST HIGHLAND WH TER
WHIPPET
WIREHAIR PNTG GRIFFN
WIREHAIRED DACHS.
WIREHAIRED FOX TERR
WIREHAIRED TERR MIX
YORKSHIRE (TERRIER)
YORKSHIRE TERR MIX
OTHER BREED
UNKNOWN
Species: CAPRINE | Breed:
(Required)
ALPINE
AMERICAN LA MANCHA
ANGLO-NUBIAN
ANGORA
BRUSH GOAT
FRENCH ALPINE
GRANADA
MOHAIR
NUBIAN
OBERHASLI
PYGMY
SAANEN
SPANISH LA MANCHA
TOOGENBURY
OTHER BREED
UNKNOWN
Species: EQUINE | Breed:
(Required)
ALBINO
ALCOCK
AM. INDIAN HORSE
AM. PAINT HORSE
AM. QUARTER HORSE
AM. WALKING HORSE
AMERICAN SADDLE
AMERICAN SHIRE
AMERICAN SUFFOLK
ANDALUSIAN
APPALOOSA
ARABIAN - ASIL
ARABIAN - BEDOUIN
ARABIAN - KUHAYLAN
ARABIAN - MUNIQI
ARABIAN
BARB
BELGIAN
BUCKSKIN
CANADIAN PACER
CICKSAW
CLEVELAND BAY
COCKSPUR
CONESTOGA
COPPERBOTTOM
CREMELLOS(CREAMALOS)
CRILLO - PASO FINO
CRIOULO (OR COSTERO)
DUTCH HORSE
DUTCH WORKHORSE
ENGLISH SADDLE HORSE
EOHIPPUS (DAWN HORSE)
EXMOOR PONY
FIORD PONY
FLEMISH HORSE
FOX - TROTTER
GALLOWAY
GOTLAND (PONY)
GRIFFIN (PONY)
HACKNEY HORSE
HACKNEY PONY
HOBBIES
ICELAND PONY
INDIAN PONY
IRISH HUNTER
JACK
JENNET
KENTUCKY SADDLER
KENTUCKY THOROBRED
LIPZZANER
MISSOURI FOXTROT
MORGAN
MUSTANG - CAYUSE
MUSTANG
NARRAGANSETT PACER
NATIONAL APPALOOSA
NORFOLK TROTTER
NORMAL HORSE
NORWEGIAN PONY
ORIENTAL
PALAMINO - ISABELLA
PALAMINO
PERCHERON
PERUVIAN PASO
PINTO - OVERDO
PINTO - TOBIANO
PINTO
PONY OF AMERICA
SADDLEBRED
SARACEN HORSE
SEQLAWI - ABAYYAN
SEQLAWI - DAHMAN
SEQLAWI - MILWAH
SEQLAWI - MU'WAJ
SEQLAWI - RISHMAN
SEQLAWI - TUWASAN
SEQLAWI
SHETLAND PONY
SHIRE
SORREL - CHESTNUT
SORREL
SPANISH JENNET
SPANISH MUSTANG
STANDARBRED
SUFFOLK
TENN. WALKING HORSE
TENNESSEE WALKER
TEXAS PONY
THOROUGHBRED
WALER
WELSH PONY
WESTLAND PONY
OTHER BREED
UNKNOWN
Species: FELINE | Breed:
(Required)
ABYSSINIANS/SOMALI
ANGORA
BALINESE
BENGAL
BRIMAN
BRITISH BLUE
BURMESE
CHARTREUX
DOMESTIC LONG HAIR
DOMESTIC MEDIUM HAIR
DOMESTIC SHORT HAIR
HAVANA BROWN
HIGHLANDER
HIMALAYAN MIX
HIMALAYAN
JAPANESE BOBTAIL
KORAT
MAINE COON CAT
MANX
NORWEGIAN FOREST
PERSIAN MIX
PERSIAN
REX
RUSSIAN BLUE
SCOTTISH FOLD
SIAMESE MIX
SIAMESE
SNOW SHOE LYNX
TABBY
TURKISH VAN
OTHER BREED
UNKNOWN
Species: LAGOMORPHA | Breed:
(Required)
DOMESTIC RABBIT
DWARF RABBIT
WILD RABBIT
OTHER BREED
UNKNOWN
Species: MUSTELIDAE | Breed:
(Required)
FERRET
OTHER BREED
UNKNOWN
Species: OVINE | Breed:
(Required)
BLACK-FACED HIGHLAND
BORDER LEICESTER
CAMBRIDGE
CHEVIOT
COLUMBIA
CORRIEDALE
COTSWOLD
DORSET HORN
FINN
HAMPSHIRE
KARAKUL
LEICESTER
LINCOLN
MERINO (DELAINE)
MONTADALE
OXFORD
PANAMA
RAMBOUILLETS
ROMELDALE
SHROPSHIRE
SUFFOLK
TARGHEE
TUNIS
OTHER BREED
UNKNOWN
Species: PORCINE | Breed:
(Required)
AMERICAN HEREFORD
AMERICAN LANDRACE
BERKSHIRE
CHESTER WHITE
CROSSBRED
DUROC X LANDRACE
DUROC
HAMPSHIRE XLANDRACE
HAMPSHIRE
LANDRACE
OHIO IMPR. CHESTER
POLAND CHINA
SPOTTED CROSS
SPOTTED POLAND CHINA
TAMWORTH
YORK X RUDOC
YORK X HAMPSHIRE
YORK X LANDRACE
YORKSHIRE
OTHER BREED
UNKNOWN
Species: PROCYONIDAE | Breed:
(Required)
RACCOON
OTHER BREED
UNKNOWN
Species: REPTILIA | Breed:
(Required)
BOA CONSTRICTOR
IGUANA
LEOPARD GECKO
PYTHON
SNAKE
OTHER BREED
UNKNOWN
Species: RODENTIA | Breed:
(Required)
GERBIL
GUINEA PIG
HAMSTER
MOUSE
RAT
OTHER BREED
UNKNOWN
Breed:
(Required)
OTHER BREED
UNKNOWN
Pet Birthdate (estimate if unknown) *
(Required)
MM slash DD slash YYYY
Pet Sex *
(Required)
Female
Gelding
Male
Mare
Neuter
Other
Spay
Stallion
Unknow
Color*
(Required)
Microchip #
Clinic pet was last seen *
(Required)
Has your pet shown signs of anxiety or aggression in a veterinary setting before? If yes, please provide details. *
(Required)
Please upload any medical records you have for your pet(s)
Max. file size: 8 MB.
If you have any other pets you would like to have on file with us, feel free to list them here:
Payment Policy
Professional fees are to be paid at the time services are rendered. We do not carry open account balances and offer the following ways to provide payment: Visa, Mastercard, Discover, Cash, Check, and Care Credit. There will be a $35 processing fee on all returned checks.
It is our policy to provide you with a written estimate whenever requested and it is your right to decline any procedures recommended, prior to the performance of those services. Deposits may be required for certain services at the discretion of the clinic.
No Show and Late Policy
At Clear Creek Animal Hospital, we strive to provide the best possible care for your pets, and efficient scheduling is crucial to ensure timely and comprehensive service. In order to better serve all of our clients, we have implemented an Appointment Cancellation Policy. Please take a moment to familiarize yourself with the following guidelines:
1. Advance Notice for Rescheduling:
To accommodate the needs of all our clients, kindly provide our office with a 24-hour notice if you need to cancel or reschedule your appointment. Failure to provide 24-hour notice may result in a $30 fee.
2. No-Show Policy
Missing an appointment with no attempt to cancel or contacting us after your appointment time has passed will result in a charge for the missed exam, which is $72.
3. Late Arrival Policy
If you are 10 or more minutes late for your appointment, it may be necessary to cancel and reschedule.
4. Reminder Calls
As a courtesy, we provide reminder calls, emails, and text messages for appointments one to two days in advance. We recommend not opting out of these communications which increases the risk of missing an appointment. Please note that if a reminder call or message is not received, the cancellation policy remains in effect.
5. Repeated Missed Appointments
Repeated instances of missed appointments may lead to the termination of the veterinarian/patient relationship.
Policy Acknowledgement
-We understand that circumstances may vary, and exceptions can be discussed on a case-by-case basis.
- If you have any questions regarding this policy, our staff will be happy to provide clarification.
- By signing and dating below, you acknowledge that you have read and understand the Appointment Cancellation Policy. Please be aware that these terms may be amended by the clinic from time to time.
Signature
(Required)
Use your mouse or finger to draw your signature above