Veterinary New Client/Patient Form

Sunbury Veterinary Clinic
12407 North Mopac Expy, Suite 400-B
Austin, TX 78758
512.255.8387
sunburyvetclinic@austin.rr.com
Owner Name: *

First Name Last Name
Owner Cell Phone #: *
Additional Phone #:
Owner Email Address: *
example@example.com
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Spouse/Partner Name:
Spouse/Partner Cell Phone #:
Name of Emergency Contact (Other than self): *
Phone # of Emergency Contact: *
How did you learn about our clinic?
PET HEALTH HISTORY
Name of Pet: *
Species: *

CANINE FELINE
Breed: *
Sex: *

MALE - INTACT MALE - NEUTERED FEMALE - INTACT FEMALE - SPAYED
Color: *
Age or Date of Birth: *
Previous clinic we can contact for records, if applicable: *
Usual diet, including brand name:
Current Medications (Including Flea and Heartworm preventions):
AUTHORIZATION
Are we permitted to post pictures of your pet(s) on social media?

YES NO
*

I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND/OR TREAT MY PETS AND I ASSUME FULL RESPONSIBILITY FOR ALL CHARGES INCURRED FOR THE CARE OF ALL MY PETS ON MY FILE. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF RELEASE AND THAT A DEPOSIT MAY BE REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION. IF MY ACCOUNT BECOMES PAST DUE (25 DAYS AFTER DATE OF SERVICE), I WILL BE RESPONSIBLE FOR ANY FINANCE OR COLLECTION CHARGES.
SIGNATURE *

Clear
DATE OF SIGNATURE *

Month Day Year
Date
Should be Empty: