Pet Owners

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.

Date

Your Name

Your Email

Subject

Phone Number

Preferred Contact Method
EmailPhone

Pet's Name

Doctor's Name

Medication Name - Prescription 1

Medication Strength (from the previous prescription)

Medication Directions (from the previous prescription)

Has your pet's medication dosage changed since the last prescription
NoYes

If yes, what is your pet's current dosage of medication (amount and frequency)

Quantity Desired
One monthTwo monthsThree monthsOther Quantity (please provide additional information below)

Other Quantity

Medication Name - Prescription 2

Medication Strength (from the previous prescription)

Medication Directions (from the previous prescription)

Has your pet's medication dosage changed since the last prescription
NoYes

If yes, what is your pet's current dosage of medication (amount and frequency)

Quantity Desired
One monthTwo monthsThree monthsOther Quantity (please provide additional information below)

Other Quantity

Pick Up Medication At
AVESPharmacy

Your Pharmacy's Name

Your Pharmacy's Telephone Number

Pet Update

Questions & Comments