 Email … Phone … South Lamar … Riverside … Circle C. … …

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Appointment

South Lamar
info@bluebonnetah.com

Riverside
bluebonnetriversidevet@gmail.com

Circle C.
circlec@bluebonnetah.com

South Lamar
512-441-3192

Riverside
512-444-3111

Circle C.
512-980-6555

Medical History
(South Lamar)

Please fill out the medical history form below, and a member of our team will get back to you shortly. We look forward to hearing from you! Please keep in mind that this form is for our South Lamar location.

Get Started

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Medical History Form

Thank you for considering Bluebonnet Animal Hospital for your pet’s needs. Please fill out the below form below in its entirety to ensure we can provide you and your pet with the best possible care.

Please Note: Any fields with * are required.

Today's Date *

Appointment Date *

Current Client Relationship *

Existing Client/Existing Patient
Existing Client/New Patient
New Client/New Patient

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Has your address changed? *

Yes
No

New Address *

Address Line 1

Address Line 2

City

State

Zip Code

Owner's Name *

First

Last

Place of Employment *

Driver's License Number *

Who else is authorized to make decisions about your pet’s healthcare? *

First

Last

Phone *

Is there someone else you would like to add as an authorized agent? *

Yes
No

My preferred pronouns are: *

Who else is authorized to make decisions about your pet’s healthcare? *

First

Last

Phone *

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Pet's Name *

Species *

Dog
Cat

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Does your pet have a microchip? *

Yes
No
I'm not sure

Is your pet's energy *

Normal
Abnormal

If abnormal, please explain *

Is your pet's appetite *

Normal
Abnormal

If abnormal, please explain *

Is your pet's thirst *

Normal
Abnormal

If abnormal, please explain *

Is your pet's urination *

Normal
Abnormal

If abnormal, please explain *

Is your pet's defecation *

Normal
Abnormal

If abnormal, please explain *

Is your pet's mobility *

Normal
Abnormal

If abnormal, please explain *

Does your cat go outside? *

Yes
No

Is your pet sneezing? *

Yes
No

If yes, how long? How often? *

Is your pet coughing? *

Yes
No

If yes, how long? How often? *

Does your pet have masses/growths? *

Yes
No

If yes, how long has your pet had them? Where are they? *

Is your pet vomiting? *

Yes
No

If yes, how long? How often? *

Does your pet have diarrhea? *

Yes
No

If yes, how long? How often? *

Is your pet itching? *

Yes
No

If yes, how long? How often? *

Name of diet fed and how much daily *

Medications and heartworm/flea prevention pet is currently on (include dosages and frequency) *

Any adverse vaccine reactions? *

Yes
No

If yes, please explain *

Any adverse medication reaction? *

Yes
No

If yes, please explain *

Any adverse anesthesia reaction? *

Yes
No

If yes, please explain *

Does your cat go outside? *

Yes
No

Previous diagnosis/medical conditions *

Any previous surgeries? *

Are there any other problems that you would like to discuss with the doctor today?

Has your pet been to another veterinarian? *

Yes
No

Name of Previous Vet Office *

Phone Number of Previous Vet Office (if known)

City & State *

Do you have another previous veterinarian to add? *

Yes
No

Name of Previous Vet Office *

Phone Number of Previous Vet Office (if known) *

City & State *

Do you have another previous veterinarian to add? *

Yes
No

Name of Previous Vet Office *

Phone Number of Previous Vet Office (if known) *

City & State *

Photo Consent: We love showing off positive pet stories and our amazing pet families! **I hereby authorize Bluebonnet Animal Hospital the right to take and publish the photos taken of me and/or my pet for use in their printed publications, social media, websites, etc. I release Bluebonnet Animal Hospital (representatives and employees) from liability for any claims by me or any third party in connection with my participation. *

The above may take photos of my pet and/or me
The above may NOT take photos of my pet and/or me

Microchip Scanning and Release of Information: Bluebonnet Animal Hospital values reuniting lost pets with their families. By signing below, you hereby authorize: (1) That we may scan any animal, you bring to our clinic for the presence of a microchip, (2) That, if a microchip is found, we may use an online look-up system and/or contact the microchip company associated with that chip to confirm whether you are the party to whom the chip is registered, (3) If the chip is registered to someone other than you, that your name and contact information above may be provided, as the person who has present custody of the animal, too (a) the microchip company, (b) the party to whom the chip is registered, and/or (c) any state or local agency including animal control and law enforcement. Whether or not the chip is registered to you, you agree and understand that: (1) You are responsible for payments to us for all services rendered today (if any are charged and quoted to you in advance), (2) You will take home the animal you brought to our clinic after services are rendered, (3) You will indemnify and hold us harmless for our actions taken in good faith as authorized above. *

I have read and accepted the microchip policy

Routine lab work is recommended by your veterinarian on a regular basis to evaluate your pet's organ values that may reveal treatable issues that may not always be seen on a physical exam. Labwork organ values can also serve as a benchmark if your pet should ever become ill in the future.

Yes, I am interested in performing lab work today (your pet's recommended panel will be discussed during your visit).
No, I am not interested in performing lab work today.

While your pet is here with us today, would you like us to update:

Nail Trim ($25)
Nail Dremel ($40)
Microchip and Registration ($78.99)
Refill Heartworm and Flea Prevention
Refill Other Medication

Medication(s) to Refill: *

A VCPR (veterinary-client-patient-relationship) must be established before the veterinarian can assess, diagnose, or treat any animal. A VCPR is maintained by an annual exam and can not be done solely by telephone or other electronic means. Any new presenting issue requires an exam by the veterinarian prior to assessing, diagnosing, or treating. *

I have read and understand the treatment policy.

I certify that I am 18 years of age and older. Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way we have to know for certain that you want us to proceed with your pet's care. We accept Cash, Visa, MasterCard, Discover, and CareCredit payments. We neither extend credit nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. *

I have read and accept the financial policy

Best phone number for today *

Email *

Please upload any relevant photos, videos, or records here:

Click or drag files to this area to upload. You can upload up to 10 files.

Microchip Scanning and Release of Information

Bluebonnet Animal Hospital values reuniting lost pets with their families. By signing below, you hereby authorize:

That we may scan any animal you bring to our clinic for the presence of a microchip.
That, if a microchip is found, we may use an online look-up system and/or contact the microchip company associated with that chip to confirm whether you are the party to whom the chip is registered.
If the chip is registered to someone other than you, that your name and contact information above may be provided, as the person who has present custody of the animal, to (a) the microchip company, (b) the party to whom the chip is registered, and/or (c) any state or local agency including animal control and law enforcement.

Whether or not the chip is registered to you, you agree and understand that:

You are responsible for payment to us for all services rendered today (if any are charged, and quoted to you in advance).
You will take home the animal you brought to our clinic after services are rendered.
You will indemnify and hold us harmless for our actions taken in good faith as authorized above.

We strive to provide a safe and welcoming environment for our clients and our employees, who work hard every day to serve our patients. We will not accept the following behaviors: verbal abuse, malicious or harmful statements about others, profanity or disrespect, any form of harassment, discriminatory comments or actions, intimidation tactics and/or making threats, allowing your pet to intimidate or threaten a person or another pet, public disclosure of another's private information, suspicion of being under the influence of alcohol or behavior-altering drugs, or failure to comply with requests of our staff such a leashing/restraining your pet. If your behavior is problematic, we reserve the right to discontinue new services. This policy is strictly enforced, and non-compliance will result in corrective measures being taken, which may include being asked to leave the property and the possible involvement of law enforcement. Thank you for your cooperation and understanding! *

I have read and understand the policy above

Signature *

Clear Signature

Ready to get started?

The doctors and staff at Bluebonnet Animal Hospital strive each and every day to deliver the highest standard in veterinary care and help you make the best decisions regarding your pet’s health by keeping you informed and in-touch with your best friend’s needs.

Forms

South Lamar

Location:
2414-B
South Lamar Blvd
Austin, TX 78704

Phone:
512-441-3192

Email:
info@bluebonnetah.com

Hours:
Mon – Fri: 7:00 AM – 6:00 PM
Sat & Sun: 8:00 AM – 2:00 PM

Riverside

Location:
2400
East Oltorf 10A,
Austin, TX 78741

Phone:
512-444-3111

Email:
bluebonnetriversidevet@gmail.com

Hours:
Mon – Fri: 7:00 AM – 6:00 PM
Sat: 8:00 AM – 12:00 PM
Sun: CLOSED

Circle C.

Location:
5700
West Slaughter Lane #380,
Austin, TX 78749

Phone:
512-980-6555

Email:
circlec@bluebonnetah.com

Hours:
Mon – Fri: 7:00 AM – 6:00 PM
Sat: 8:00 AM – 12:00 PM
Now Open!

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