Client Information Form Pet Specialists Of Austin

*Initial exam fee is $183.31. Exam fee payment is expected at time of visit. You may be required to leave a deposit before a procedure.

Owner Name*

First NameLast Name

Co-Owner Name

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Secondary Email

example@example.com

Patient Name*

DogCat

Breed

MaleNeutered MaleFemaleSpayed Female

If applicable, last heat cycle:

Birth Date / Age

Coat Color

Indoor onlyOutdoor onlyMixed indoor and outdoor

Who is your primary care veterinarian?

What is your primary care clinic name?

YesNo

Please list what vaccinations your pet is current on:

Please list the date of your pet's last rabies vaccination:

What is the reason for today's visit?*

YesNo

If yes, please list:

List all current medication your pet receives and include strength, dosage schedule, and last date given for each (including heartworm/flea prevention medication):

What brand of food does your pet eat? How much is given each day? (Please include treats as well)

YesNo

Yes, I give permission for Pet Specialists of Austin to share my pet's picture and story.No

Following the doctor’s examination, you will be provided an estimate of fees. All fees are due at time services are rendered. Furthermore, you will assume financial responsibility for all charges incurred in the care of this pet. Pet Specialists of Austin urges you to discuss all fees with the Doctor/Nurse Staff before services are performed. Pet Specialists of Austin accepts cash, check (With appropriate identification and check approval), all major credit cards, Care Credit and Scratch Pay. *

Date

DNR (DO NOT RESUSCITATE) - if your pet's heart or breathing stops, you do not want us to administer supportive treatments (allow your pet to die naturally)CPR - I authorize limited, non-surgical resuscitative CPR efforts, if deemed necessary in the attempt to keep my pet alive. There is no guarantee the efforts will be successful. I will pay all costs incurred in the resuscitative efforts. These costs are NOT included in the initial estimate. This is estimated as an additional $800-1000.

Client Information Form

Patient Information