New Client Information Form « Manchaca Village Veterinary Care

12117 Manchaca Rd.
Austin TX 78748
Tel: 512-282-1326
Fax: 512-291-4392
vet@manchacavet.com

Over 25 Years of Experienced &
Compassionate Pet Care
in South Austin

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Emergency!
During operating hours,
call us at 512-282-1326.
After-hours, please call:
512-899-0955

“I am pleased with the staff, your willingness to see my pups for flu vaccine, and your pro-activeness to offer the vaccine. My dogs were not jumpy or nervous to go to a new place and I believe as there was no hospital smell were very much at ease. I have changed my fur kids over to your practice based upon what I saw and how the staff treated us. Thank you.” —Linda Y.

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Thank you, your form has been submitted.
For any additional pets, please use the Additional Pets Form.

Since your pet is new to us, we'd like to extend this First-Time Patient Special to you and your pet!

New Client Information Form

Thank you for choosing us for your pet care needs. So that we may provide the most comprehensive care for your pet, please complete the form below. Required fields are in bold.

Full name of owner:

Full name of spouse/other:

Address 1:

Address 2:

City:

State:

Zip:

Primary phone:

Work phone:

Home/cell phone:

Email address:

Spouse’s cell or work phone:

Appointment reminders via Text Message?

Yes No

Monthly Heartworm reminders via Text Message?

Yes No

What day of the month do you want the Heartguard reminder?

Cell Number for Text Messages:

Name of pet:

Sex:

Type:

Dog Cat

Breed:

Long-hair Medium-hair Short-hair Other

Please specify:

Age:

Color:

When, by what Vet, and in what City was your pet last vaccinated?

Would you like for us to call your previous vet to have your records transferred to us?

Yes No I’ll provide a copy

Chronic ailments:

Yes No

List Ailments:

Please list all medications given and when (including Over-The-Counter):
Use as many lines as necessary.

Has your pet been tested for heartworms?

Yes No

If yes, state when?

Any prior illness or injury we should know about?

Yes No

If yes, what & when?

Do you have your pet groomed?

Yes No

Is your pet boarded at times?

Yes No

Do you use your pet for hunting, sporting or camping?

Yes No

On average, how many hours a week is your pet outdoors?

How did you hear about us?

Please specify:

So we may show our thanks, whom were you referred by?

Do you already have an appointment set up with us?

Yes No

Date and time of appointment:

Choose the best description that generally describes the reason for the appointment:

Terms and Condidtions We will gladly prepare a written estimate if you desire (please ask our doctor OR technician). This will be important to you since ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. In cases of extensive medical or surgical procedures, when full payment may be difficult, we take MasterCard, Visa and Discover. There will be a $25.00 service charge for any check returned unpaid. To prevent the spread of infectious diseases, all hospitalized and boarded patients must be current on all vaccines and free from internal and external parasites. By submitting this form you authorize this level of preventive care. Appropriate charges will be assessed on the discharge invoice.

I understand and agree with the terms and conditions