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Client Information
Owner Information
Owner Name
(Required)
First
Last
Owner Address
(Required)
Street Address
Address Line 2
City
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State
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Owner Home Phone
(Required)
Owner Cell
Owner Email
(Required)
Enter Email
Confirm Email
Would you (Owner) like to receive information and updates from GCVS?
(Required)
Yes
No
Co-Owner Information
Co-Owner Name
First
Last
Co-Owner Home Phone
Co-Owner Cell
Email
Enter Email
Confirm Email
Would you (Co-Owner) like to receive information and updates from GCVS?
(Required)
Yes
No
Authorized Agent If Owners Are Not Present
Authorized Agent Name
First
Last
Authorized Agent Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Authorized Agent Agent Home Phone
Authorized Agent Cell Phone
Patient Information
Patient Name
(Required)
Breed
(Required)
Color
(Required)
Species
(Required)
Dog
Cat
Other
Gender
(Required)
Male
Female
Neutered
(Required)
Yes
No
Date of Birth
(Required)
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
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29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
If other than a dog or cat, list type of animal
Pet Insurance Company
Policy Number
Referral Information
Name of Pet’s Veterinarian and/or Hospital
Consent to Release Records
(Required)
I hereby authorize release of my pet’s medical records to my veterinarian listed above
I do NOT authorize release of my pet’s medical records to my veterinarian.
Authorized Person(s)
I authorize release of my pet’s medical records to
Who we should release the records to
We love a happy ending!
Can we share your pet's photo/or story?
Permissions to Share Photo/Story
By checking this box, I give permission
I give Veterinary Specialists of Texas, P.C. (DBA Gulf Coast Veterinary Specialists) the right to create, edit, copy and make use of my pet’s image and my pet’s treatment story in and/or for promotional materials including, but not limited to social networking sites, websites, newsletters, flyers, posters, and brochures, without payment or any other consideration. I understand and agree that any images of or treatment stories about my pet are the property of Gulf Coast Veterinary Specialists and will not be returned to me. I waive and release Gulf Coast Veterinary Specialists from all claims arising from Gulf Coast VeterinaryYes
Payment Information & Animal Bite Policy
Payment Information
(Required)
By checking this box, I agree to pay for all services rendered.
Following the doctor’s examination, we will provide you with an estimate of fees. All professional fees are due at the time services are rendered, with a partial payment required to begin diagnostics, surgery, and/or treatment. We accept cash, check (with appropriate identification and check approval), major credit cards; or we can help you establish a payment arrangement if approved by Wells Fargo Health Advantage or Care Credit in advance of treatment. There will be a service charge for any check returned unpaid. We urge you to discuss all fees with the doctor before services are performed.
Animal Bite Policy
(Required)
By checking this box, I agree to the policy.
In the event that your pet bites a staff member during the course of treatment, per Harris County regulations, your pet will be quarantined for a period of 10 days. GCVS charges a fee of $12 per day for bite quarantine. By signing this form today, I agree that I am the owner or agent for the owner, of the pet I am presenting for evaluation today and have the authority to sign, comply, am financially responsible and consent to the procedures described to me as well as to provide timely payment for services.
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Email
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