Client Information Form - Gulf Coast Veterinary Specialists

Owner Information

Owner Name(Required)

First Last

Owner Address(Required)

Street Address Address Line 2 City State ZIP Code

Owner Home Phone(Required)

Owner Cell

Owner Email(Required)

Enter Email Confirm Email

Would you (Owner) like to receive information and updates from GCVS?(Required)

Yes
No

Co-Owner Information

Co-Owner Name

First Last

Co-Owner Home Phone

Co-Owner Cell

Email

Enter Email Confirm Email

Would you (Co-Owner) like to receive information and updates from GCVS?(Required)

Yes
No

Authorized Agent If Owners Are Not Present

Authorized Agent Name

First Last

Authorized Agent Address

Street Address Address Line 2 City State ZIP Code

Authorized Agent Agent Home Phone

Authorized Agent Cell Phone

Patient Information

Patient Name(Required)

Breed(Required)

Color(Required)

Species(Required)

Dog
Cat
Other

Gender(Required)

Male
Female

Neutered(Required)

Yes
No

Date of Birth(Required)

If other than a dog or cat, list type of animal

Pet Insurance Company

Policy Number

Referral Information

Name of Pet’s Veterinarian and/or Hospital

Consent to Release Records(Required)

I hereby authorize release of my pet’s medical records to my veterinarian listed above
I do NOT authorize release of my pet’s medical records to my veterinarian.

Authorized Person(s)

I authorize release of my pet’s medical records to

Who we should release the records to

We love a happy ending!

Can we share your pet's photo/or story?

Permissions to Share Photo/Story

By checking this box, I give permission

I give Veterinary Specialists of Texas, P.C. (DBA Gulf Coast Veterinary Specialists) the right to create, edit, copy and make use of my pet’s image and my pet’s treatment story in and/or for promotional materials including, but not limited to social networking sites, websites, newsletters, flyers, posters, and brochures, without payment or any other consideration. I understand and agree that any images of or treatment stories about my pet are the property of Gulf Coast Veterinary Specialists and will not be returned to me. I waive and release Gulf Coast Veterinary Specialists from all claims arising from Gulf Coast VeterinaryYes

Payment Information & Animal Bite Policy

Payment Information(Required)

By checking this box, I agree to pay for all services rendered.

Following the doctor’s examination, we will provide you with an estimate of fees. All professional fees are due at the time services are rendered, with a partial payment required to begin diagnostics, surgery, and/or treatment. We accept cash, check (with appropriate identification and check approval), major credit cards; or we can help you establish a payment arrangement if approved by Wells Fargo Health Advantage or Care Credit in advance of treatment. There will be a service charge for any check returned unpaid. We urge you to discuss all fees with the doctor before services are performed.

Animal Bite Policy(Required)

By checking this box, I agree to the policy.

In the event that your pet bites a staff member during the course of treatment, per Harris County regulations, your pet will be quarantined for a period of 10 days. GCVS charges a fee of $12 per day for bite quarantine. By signing this form today, I agree that I am the owner or agent for the owner, of the pet I am presenting for evaluation today and have the authority to sign, comply, am financially responsible and consent to the procedures described to me as well as to provide timely payment for services.

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Comments

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