Northwest Austin Veterinary Center

> Contact
New Client Form
> Appointment Request Form
> RX/Food Reorder Form

Avoid the paperwork and wait associated with your first visit. Complete and submit this form prior to our first appointment and all you will need to do is sign the completed forms at our office. You will be asked to sign and date a printout of this form when you come in for your first appointment.


Your Name
Street Address
City, State, Zip
Home Phone
Work Phone
Occupation
Employer	Name, address, phone
Mobile Phone
E-mail
Alternate Contact:
Alternate Contact Name
Alternate Contact's Relation to You
Alternate Contact's Phone
Alternate Contact's Street Address
Alternate Contact's City, State, Zip
Alternate Contact's Occupation
Employer	Name, address, phone
Is this person authorized to make decisions about your pet’s health? Yes No
How did you first learn of our hospital?
Were you referred by someone?
# of Pets in Your Household
Pet Information:
Pet Name
Species	Dog Cat Other
If Other Species
Breed
Description/ Color
Sex	Male Female
Date of Birth
Neutered/Spayed?	Yes No
Microchipped?
Previous Hospital/ Vet	name, address, phone
Vaccination Dates	Lyme DHPP Bordatella Rabies FVRCP FELV
Current Medications	name, dosage
Prior Illness/ Accidents
Prior Surgery/ Dentistry
Disclaimer (read-only)	PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED • To prevent the spread of infectious diseases and parasites, we recommend animals be current on all vaccines. Pets with fleas will be treated with a topical or oral flea medication on admission, and the prescription price will be included in the invoice. I authorize administration of vaccines and parasite control as needed for my pet(s). • In admitting my pet(s) for diagnostics, treatment, boarding, or surgery, I authorize the veterinarians of Northwest Austin Veterinary Center, and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary. At your request we will gladly discuss cost of services and/or prepare a written estimate for recommended procedures. Professional fees are due at the time services are rendered. • I assume full financial responsibility for all charges incurred by my pet. I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted, if possible, prior to treatment should complications occur.
When you are finished, click submit to send the form information