Client Registration Form

*Initial and Emergency exam fees range from $125 - $185. Exam fee payment expected at the time of the visit

*For your safety and ours: PLEASE make sure to have your mouth and nose covered while interacting with our team members.

CLIENT INFORMATION

Select Location *

Please note that our North location is currently closed.

First Name *

Last Name *

Spouse/Other

Address *

City/St/Zip *

Best Contact (Phone) *

Secondary Contact (Phone) *

Employer

Work Phone

Email *

Secondary Email *

PATIENT INFORMATION

Pet's Name *

Type *

Breed *

Age/DOB *

Color *

Sex *

Is your pet spayed or neutered (altered/fixed)? *

Yes

Vaccines Current *

Date of last Rabies vaccination *

Primary Care or Referring Veterinarian *

Clinic/Hosp Name *

Address

Phone

Reason for Visit *

Treated for any illnesses in the past year?

If yes, please note problem(s) & treatment(s)

Did your referring veterinarian send you with (select all)

X-Rays

Records

Resuscitation Directive

IMPORTANT: Please thoroughly read the Resuscitation Directive before selecting your option below

By selecting my option below, I have read the Resuscitation Directive and understand the CPR options below and in the event my pet experiences respiratory and/or cardiac arrest I authorize Central Texas Veterinary Specialty & Emergency Hospital to act according to my choice below. *

Attempt Resuscitation

Do Not Resuscitate

Client Rights/ Responsibilities Agreement

IMPORTANT: Please thoroughly read the Client Rights and Responsibilities before selecting your option below

I have read the Client Rights and Responsibilities Agreement and agree to the terms *

I agree to the terms of the Client Rights and Responsibilities

I give CTVSEH, LLC permission to post appropriate photos of my pet on social media sites (Facebook, Twitter, etc) *

NOTE: Each department of our hospital specializes in a specific area. If your pet has any problems not related to our specialty, please consult with your family veterinarian for those problems.

“I, the undersigned, understand that no guarantee may be made as to the results obtained from medical/surgical treatment, Furthermore, I assume financial responsibility for all charges incurred in the care of this pet. I understand that the examination fee is incurred at the time this pet is examined and that all charges must be paid in full at the time services are provided when the pet is discharged/ released.”

Client Signature

Please use cursor to sign below

Client Registration Form

*Initial and Emergency exam fees range from $125 - $185. Exam fee payment expected at the time of the visit

IMPORTANT: Please thoroughly read the Resuscitation Directive before selecting your option below

IMPORTANT: Please thoroughly read the Client Rights and Responsibilities before selecting your option below

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