Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Animal Information

TCM Survey

Please check any boxes below that apply to your pet.

FIRE

WOOD

EARTH

WATER

METAL

Yang (Heat) and Yin (Cold)

Please select all the traits that apply to your pet. If you are unsure or your pet is “Normal” or “Neutral” leave the Yang/Yin item unchecked.

Further Questions

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a second pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a third pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat

Do you agree to receive text messages from Mountain Veterinary Hospital? *

I agree

By checking this box, you consent to receive informational and/or promotional text messages from Mountain Veterinary Hospital at the number provided, including messages sent by the autodialer. Consent is not a condition of purchase. Message & data rates may apply. Message frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help. Privacy Policy.

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a fourth pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a fifth pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Payment is due in full at the time services are performed. If your pet is admitted to the hospital, we cannot begin care until you have confirmed that you would like us to proceed by 1) signing the client consent and estimate form, and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way we can know for certain that you want us to proceed with your pet’s care. We accept cash, checks, debit cards, Visa, MasterCard, American Express, and Discover. We also offer financing through CareCredit and Scratchpay; learn more on our Payment Options page. We do not extend credit or bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. *

I have read and accept the financial policy.

First Alternative Medicine Exam Form

Complete Your Alternative Medicine Exam Form

Please Fill Out the Details Below

Animal Information

TCM Survey

FIRE

WOOD

EARTH

WATER

METAL

Yang (Heat) and Yin (Cold)

Further Questions

What to Expect After You Submit

Schedule Your Pet’s Visit Today

Have a Question?

Contact Us

Location

Hours