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

Referring Doctor*

Hospital Name*

Reason for Referral*

Primary Doctor

(if different than referring)

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

Yes
No

PAYMENT POLICY

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 $25 fee will be added to all returned checks. Any unpaid balances carried to the following month will accrue an interest rate of 2% per month compounded. Statements will be sent at the end of each month and past due accounts will subsequently be turned over to a collection agency for collection of all unpaid balance, plus interest, and collection fees.

Signing individual must be at least 18 years of age.

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.