Change of Owner Form

Change of Owner

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Day-Time Phone*

What type of phone is this?*

mobile/cell
work
home

Email*

Co-owner Information (optional)

Name

First Last

Phone

Pet Information

Your name for this pet*

Name of your pet when owned by the previous owner*

Name of Previous Owner*

Please enter the name of the owner of your pet at the time they were our patient. For example, if you adopted from a Rescue group, and your pet was treated here previously under that Rescue, then please enter the Rescue's organization name.

Date you became the new owner*

Primary Veterinarian Clinic (enter "n/a" if no regular vet). If your primary veterinarian has multiple locations (Banfield, Thrive, Zippivet, VCA, etc) please specify location.*

Please describe your pet's medical condition, illness or injury. Be as specific as possible about anatomical location.*

When did you first notice the problem?*

Has this problem been diagnosed by a veterinarian?*

Yes
No

If Yes, which vet, hospital or clinic diagnosed your pet's condition?

What is the diagnosis?

Were x-rays taken?*

Yes
No

If x-rays were taken, were they done under sedation?

Yes
No
I don't know

Date of these x-rays

Has your pet had blood work performed in the past 3 months? (do not include if done just for heartworms)*

Yes
No
I don't know

Is your pet on any medications or supplements?*

Yes
No

If Yes, please list the medication or supplement

Please do not opt out from receiving our texts/emails. We only send essential communications. Opting out will delay the scheduling of next steps for your pet.*

I understand

I understand that my pet’s medical case will not be reviewed until I have ensured that all relevant medical notes and existing diagnostics (such as x-rays, bloodwork results, etc., if applicable) are emailed to Veterinary Surgical Solutions at surgery@vssaustin.com. To confirm that all information is received, it is recommended to have your veterinarian include you in the email. We cannot proceed with any next steps or schedule appointments until this information has been received and reviewed.*

I understand

Change of Owner

Co-owner Information (optional)

Pet Information

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