Client Information - Gulf Coast Veterinary Specialists

Owner Information

Owner Name*

First Name Last Name

Address*

Street Address Apt # (if applicable) City State / Province / Region ZIP / Postal Code

Primary Phone*

Email Address*

Co-Owner/Authorized Agent Information

Name

First Last

Primary Phone

Email Address

Patient Information

Patient Name*

Breed*

Color*

Species*

Dog
Cat
Other

If other, list type of animal:

Sex

Male
Female

Neutered/Spayed*

Yes
No

Date of Birth/Approx. Age:

Pet Insurance Company:

Policy #

Name of Pet’s Primary Veterinarian and/or Hospital:

Social Media Release

I agree to the social media release policy below.

Yes, I give Gulf Coast Veterinary Specialists (GCVS) permission to use my pet’s photo and treatment story for promotional
purposes, including social media, websites, newsletters, and brochures. I understand these materials are GCVS property and waive any
claims related to their use.

Records and Communication Policy*

I agree to the records and communication policy below.

Gulf Coast Veterinary Specialists is part of your pet’s continuum of care, and we may provide your family veterinarian, any specialists, and/or
a reviewing body information regarding your pet’s treatment and/or condition. By signing below, you are authorizing Gulf Coast Veterinary
Specialists to share your pet’s medical record with a third party (such as your family veterinarian) or its agent necessary for us to provide
continuous veterinary care to your pet. You agree that we (or our agents) may send you communications to your contact information
provided above regarding your pet.

Payment Policy*

I agree to the payment policy below.

A deposit will be required prior to treatment and/or hospitalization. Full payment for services rendered is required prior to discharge of your
pet from the hospital. I am aware that all diagnostics, treatment and medication charges are in addition to any examination fee and agree to pay all charges incurred at the time of service.

Consent To Treat*

I agree to the consent to treat policy.

I, the undersigned, do hereby certify that I am over the age of 18 and am the owner (or authorized agent) of the above-described patient. I
authorize Gulf Coast Veterinary Specialists (and its affiliates, employees, agents and contractors) to receive, examine, prescribe for and
treat the above-described pet. I acknowledge that pre-existing or congenital conditions, such brachycephalic airway syndrome, can
increase the risk of complications associated with treatment. I further understand that no guarantee of successful treatment is made, and I
will not hold Gulf Coast Veterinary Specialists (or its affiliates, employees, agents or contractors) responsible for my pet’s recovery.

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Email

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