Client & Patient Info Form

CLIENT INFORMATION

Owner Name*

(Last Name, First Name)

Primary Phone*

Home Address*

Street Address Address Line 2 City State ZIP Code

E-mail Address

Co-Owner Name

(Last Name, First Name)

Co-Owner Contact #

Are you an active or retired member of the U.S Military?*

Patient Information

Patient Name*

Choose One:*

Dog
Cat

Choose One:*

Male/Intact
Male/Neutered
Female/Spayed
Female/Intact

Breed*

Birth Date/Age*

Color*

Who is your pet's primary care veterinarian?

Primary Care Clinic Name

Primary Care Clinic Location

Referring Veterinarian Name

Referring Clinic Name

Referring Clinic Location

Reason for Referral (primary concern)*

If applicable, who is your Pet Insurance Provider?

Policy #

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

Have any doctors at Austin Veterinary Emergency and Specialty Center seen any of your pets in the past?*

Yes
No

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

3. Did you bring in (or email) X-rays and/or medical records from your veterinarian?*

Yes
No

Had you heard about our hospital prior to this referral?*

Yes
No

If yes, how

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

Photo Release*

Do you give Austin II, PLLC (DBA Austin Veterinary Emergency & Specialty Center) the right to create, edit, copy and make use of my pet’s image and my pet’s treatment story in and/or for promotional materials including, but not limited to social networking sites, websites, newsletters, flyers, posters, and brochures, without payment or any other consideration. I understand and agree that any images of or treatment stories about my pet are the property of Austin Veterinary Emergency & Specialty Center and will not be returned to me. I waive and release Austin Veterinary Emergency & Specialty Center from all claims arising from Austin Veterinary Emergency & Specialty Center’s use of my pet’s image or treatment story.

Yes
No

Consent*

I understand and agree that any images of or treatment stories about my pet are the property of Austin Veterinary Emergency & Specialty Center and will not be returned to me. I waive and release Austin Veterinary Emergency & Specialty Center from all claims arising from Austin Veterinary Emergency & Specialty Center’s use of my pet’s image or treatment 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.

Signature of Responsible Party*

(Must be over 18 years of age)

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Phone

This field is for validation purposes and should be left unchanged.

Client & Patient Info Form

CLIENT INFORMATION

Patient Information

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

Payment Information

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512-343-2837

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