Forms

Please fill-out the Client/Patient Information Form prior to your appointment. This will save you time when checking in.

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Owner Name:

Co-Owner Name:

Home Address:

City:

State:

Zip:

Home Phone:

Owner Information

Employer:

Work Phone:

Cellular Phone:

Alternate Number:

Email Address:

Co-Owner Information

Employer:

Work Phone:

Cellular Phone:

Alternate Number:

Email Address:

PATIENT INFORMATION

Patient Name:

Choose One:
DOGCAT

Breed:

Choose One:
Male/IntactMale/NeuteredFemale/SpayedFemale/Intact

Last Heat Cycle:

Birth Date/Age:

How long have you owned this pet?:

Color:

Where did you acquire pet?:
BreederIndividualShelterPet ShopRescue

Are Vaccinations Current?:
YesNo

Referring Veterinarian Name:

Clinic Name:

Reason for Referral (primary complaint):

Please list any of your pet’s drug allergies or special problems that we should know about:

Have any doctors at Austin Veterinary Emergency & Specialty Center, Mission Veterinary Specialists in San Antonio or Gulf Coast Vet Specialist in Houston seen any of your pets in the past?:
YesNo

If yes, which doctor(s) and which pet(s):

Had you heard about our hospital prior to this referral?:
YesNo

If yes, how:

Did you bring (or mail in) X-rays and/or medical records from your veterinarian?:
YesNo

We are always looking for patient stories to share with our Facebook community! Check here if you are ok with us posting your pet’s story on our page:

Yes I am okay with Austin Veterinary Emergency & Specialty Center sharing my pet's picture and story. :

Payment Information

Following the doctor’s examination, we will provide you with an estimate of fees. All professional fees are due at the time services are rendered, with a 75% partial payment required to begin diagnostics, surgery, and/or treatment. We accept cash, check (with appropriate identification and check approval), and all major credit cards.. There will be a service charge for any check returned unpaid. We urge you to discuss all fees with the doctor before services are performed.

Austin Veterinary Emergency & Specialty Center is comprised of multiple practices within the building. Charges that are assessed for your pet will be billed separately through each appropriate practice. If you have any questions, please be sure to ask any of our front desk staff.


First Name

Last Name

Patient Name

Date

What symptoms have you observed at home?

How long have the symptoms been present?

Did the symptoms start suddenly?

Are the symptoms:

Is your pet otherwise normal?

Are there other medical problems we need to know about?

Has your pet had any previous surgery other than spay or neuter?

Is your pet on any medication?

What medication(s) has your pet taken for this problem in the past?

If medications are being used to treat the condition for which we are evalutating your pet, have they been associated with any improvement in the condition?

Have medications been previously used that were NOT successful?

Please list ALL medications your pet currently taken for UNRELATED problems

Did you bring any radiographs or lab test results?

Did you bring any Medical Records?

What kind of food do you feed your pet?

What types of snacks/treats do you feed your pet and how often?

Do you have other pets?:

 


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512-343-2837

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