New Patient Admission – Veterinary Specialists of North Texas

OWNER’S INFORMATION

Owner's Name*

First Last

Spouse/Partner

First Last

Address*

Street Address City State ZIP Code

Primary Phone*

Secondary Phone

Email Address*

PATIENT INFORMATION

Patient’s Name*

Type*

Dog
Cat

Breed*

Color*

DOB or Age

Sex*

Male
Female
Male Neutered
Female Spayed

History of Aggression, Toward:*

Select All
Dogs
Cats
People
None

Referring Doctor*

Hospital Name*

Reason for Referral*

Primary Doctor

(if different than referring)

Life-Saving Measures*

In the event of an emergency where my pet requires intervention, and I am unable to be reached by the contact numbers I have provided, I hereby authorize the staff at VSNT to perform these emergency procedures.

Do Not Resuscitate (DNR)
Emergency Drugs/External Cardiopulmonary Resuscitation (CPR)

Images of my pet may be used for educational or marketing purposes*

Yes
No

CLIENT AGREEMENT

Please select your choice of payment*

Select All
Credit Card
Cash
Check

Signature of Owner/Responsible Party*

I agree to the payment policy.

Payment in full is due when services are rendered. A deposit may be required before extensive testing may be done. A detailed estimate will be provided prior to any procedures. In order to avoid future misunderstandings, please thoroughly discuss your pet’s treatment plan and fees with the doctor prior to approving any services.

A $35 fee will be added to all returned checks.

Signing individual must be at least 18 years of age.

Signature of Owner/Responsible Party*

I agree to the client policy.

As a Client of VSNT, I, and anyone seeking treatment on my pet’s behalf, agree to treat staff with respect and dignity whether in the hospital or on the phone, use a normal tone of speech when speaking with the staff, and refrain from using profanity. If I fail to do so, I understand that I will be asked to seek treatment elsewhere.

Signing individual must be at least 18 years of age.

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