Client & Patient Info Form

Owner Name*

Co-Owner Name

Home Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Owner Information

Owner Employer

Work Phone

Cellular Phone

Alternate Number

Email Address

Co-Owner Information

Co-Owner Employer

Work Phone

Cellular Phone

Alternate Number

Email

Patient Information

Patient Name

Choose One:

Dog
Cat

Breed

Choose One:

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

Last Heat Cycle

Birth Date/Age

How long have you owned this pet?

Color

Where did you acquire pet?

Are Vaccinations Current?

Yes
No

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?

Yes
No

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

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 here if you are ok with us posting your pet’s story on our page:

Consent

Yes, I give Gulf Coast Veterinary Surgery – 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.

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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Owner Information

Co-Owner Information

Patient Information

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:

Payment Information

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512-343-2837

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