Client Registration Form

Name: Veterinarian
Brand: Central Texas Veterinary Specialty & Emergency Hospital

Choose one:

Select Location

First Name

Last Name

Spouse/Other

Address

City/St/Zip

Best Contact (Phone)

Secondary Contact (Phone)

Employer

Work Phone

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

Sign above

We offer 24-hour emergency care at both of our locations.

Client Registration Form

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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Central Texas Veterinary Specialty & Emergency Hospital