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:
ProgressingStaying the sameImproving

Is your pet otherwise normal?
YesNo

Are there other medical problems we need to know about?

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

Is your pet on any medication?
YesNo

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?
YesNo

Did you bring any Medical Records?
YesNo

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?:
YesNo

Your Name (required)

Your Email (required)

Patient Name (required)

Basic history:

Has your pet traveled outside of Texas in the past? If so, where and how recently?

If you know what kind of food your pet is eating, what brand or flavor is it?

If you don’t, can you tell us if it is a dry food, a canned food, or a homemade food?

When was your pet changed to its current diet (estimations are okay such as "many years ago" vs "few weeks ago")?

Is your pet currently getting monthly flea, tick, and heartworm preventive? If so, what is the product?

To your knowledge, has your pet had any blood transfusions?
YesNoUnsure

Other than the pet we are seeing here today, how many other pets do you have and what kind of pets are they? (ex: 1 other dog and 2 cats)

Current Concerns:

Write the best description of how long your pet’s current signs have been happening. (some examples of clinical signs: coughing, sneezing, vomiting, not eating, being lethargic, etc)

Options: my pet is acting normally, few days, few weeks, few months, few years

On a scale of 1-10, please write how severe your pets clinical signs were when they started
1 = totally normal for your pet
10 = most severe signs you’ve ever noted

On a scale of 1-10, please write how severe your pets clinical signs are at the current time
1 = totally normal for your pet
10 = most severe signs you’ve ever noted

Based on any previous veterinary treatments (special diets, medications, therapies) for the current problems, have you noted any improvement in clinical signs at home?
YesNo

If yes, do you remember which treatment or medication you feel helped?

Based on any previous veterinary treatments (diets, medications, therapies) for the current problems, have you noted any worsening of clinical signs or development of side effects?
YesNo

To your knowledge, has your primary veterinarian sent over records for today’s visit?
YesNo

Is there any other emergency or veterinary clinic we should contact to get all of your pets information for the current problem?

Your Name

Email

Patient Name

What symptoms have you observed at home?

How long have the symptoms been present?

Are the symptons:
ProgressingStaying the sameImproving

When did your pet last receive a professional dental cleaning under anesthesia?

Has your pet had previous tooth extractions?

How long have the symptoms been present?

Has your pet ever received other advanced dental procedures (root canal, etc.)? Please Explain.

Do you provide dental home care?
YesNo

For how long?

Type of home care:

Tooth brushing

How often?

Dental chews/treats

What kind?

Water additive

What brand?

Does your pet chew on toys or bones? If so, what type and how frequent?

Water additive

Is your pet otherwise normal?

Or are there other medical problems we need to know about?

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

If yes, what kind of surgery?

Is your pet on any medication?
YesNo

What medication(s) is your pet currently taking for this problem?

What medication has your pet taken for this problem in the past:

If medications are being used to treat the condition for which we are evaluating 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 takes for UNRELATED problems:

What kind of food do you feed your pet?

How much per day?

What types of snacks/treats do you feed your pet and how often (if not listed above)?

Do you have other pets?
YesNo

What breeds or species?