Circle C Animal Hospital

9600 Escarpment Boulevard, Suite 950
Austin, TX 78749

(512)288-5888

circlecanimalhospital.com

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check-in by submitting this form.

Thank you for your cooperation!

New Client

Your Name (required)
First Name (required)
Last Name (required)
Spouse/Partner
First Name
Last Name
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Home Phone (required)
Phone TypePhone Number (required)
Cell Phone
Phone TypePhone Number
Work Phone
Phone TypePhone Number
Preferred Phone Number
Home
Cell
Work


E-Mail Address (required) :
Place of Employment

How did you hear about us?

************************Your Pet's Information************************************
Pet's Name (required)

Species (required)
Canine
Feline


Breed:

Sex: (required)
Male
Female


Neutered/Spayed: (required)
Neutered
Spayed
Neither


Color:

Date of Birth:

Current Diet:

Microchip/Tattoo#:

Does your pet have any vaccine allergies/reactions?

Please list all medications your pet is currently taking (including heartworm & flea prevention.)

Reasons or conditions that prompted your visit?

Special requests or conditions?

Does your pet have medical records at another veterinary practice?
Yes
No


Name of former veterinary practice?

Requesting Medical Records
Note: Due to privacy laws, some veterinary clinics will not release medical records to Circle C Animal Hospital without your consent. Please contact your previous veterinarian and request that all records be faxed to Circle C Animal Hospital at 512-288-6807.
************************************************************************************
Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Circle C Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Circle C Animal Hospital's collection agency and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree



Check the reCAPTCHA to ensure you are not a robot: