Registration Form – Exotic Patient

Owner's Name*

First Last

Co-Owner's Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Co-Owner Phone*

Primary Cell Number

Email*

Enter Email Confirm Email

Authorized Owner’s Agent #1 Name

First Last

Authorized Owner’s Agent #1 Phone

Authorized Owner’s Agent #2 Name

First Last

Authorized Owner’s Agent #2 Phone

B. (Who can discuss risks/benefits with veterinarian and make medical decisions for my pet). I understand that my veterinarian will need to communicate with me, the co-owner, or my authorized agent, prior to treatment of my pet(s) in order to obtain informed consent per the State of Wisconsin. For purposes of informed consent, I direct my veterinarian as follows: Informed consent may ALSO be provided by the agents above, in the order listed.

Yes
No

Date

Cancellations

Late Arrivals: If you are more than ten (10) minutes late for your pet's appointment, our staff will ask your doctor to help determine when best to see you. You may be worked into the schedule with or without a wait, you may be given the next available appointment or it may be necessary to reschedule.*

Yes
No

24 Advance Notice: If you wish to change or cancel an appointment, we appreciate a 24-hour advance notice. Advance notice allows another pet to use the appointment time. Appointments canceled less than 24 hours before the scheduled time may be considered a missed appointment.*

Yes
No

Missed Appointments: If you miss your first appointment as a new client without 24-hour notice, you may not be accepted into this practice. If you are an established client and miss three or more appointments within a year without 24-hour notice, you will be asked to pre-pay for the exam which can only be used on the date scheduled.*

Yes
No

Disclosure of Information

Wisconsin law (Stat. 453.075) requires written permission to release your pet's health records to certain third-parties (non-owners) such as boarding facilities, rescues, and other veterinary clinics.

Do you authorize us to release your pet's health records.*

Yes
No

I consent to Care Animal Hospital taking photographs and videos of my pet for educational and marketing purposes. I waive any claims or rights of compensation or ownership regarding such uses and understand that all media shall remain the proper of Care Animal Hospital.*

Yes
No

I consent to Care Animal Hospital contacting me by e-mail and by text message for the purposes of health information and reminders. I will update my number or notify Care if it’s no longer in my possession. *

Yes
No

Electronic Consent

By typing my name below as my electronic signature, I certify that I am the primary owner listed above, I am at least eighteen (18) years of age, and this information is correct to the best of my knowledge. I further acknowledge that no guarantee has been made as to the results that may be obtained. I understand that complications may arise which cannot be predicted and that I will be held financially responsible for any veterinary medical care necessitated by complications. By typing my name below, I consent to the practice contacting me by e-mail and by text message for the purpose of health information and appointment reminders. I will ensure that I keep the practice informed of my up to date mobile number at all times, or if the number is no longer in my possession. PAYMENT IN FULL IS EXPECTED AT THE TIME OF SERVICE

Name

First Last

Pet Information

Pet's Name*

Species*

ID#/Band/Microchip*

Variety*

Sex (Please indicate if spayed or neutered)*

Color*

Date of Birth or Age*

Previous Veterinary Practice (if any)*

What is the best phone number to reach you during your appointment?*

If intact female, any litters or clutches?*

Yes
No

If yes, any complications?*

Length of time in current household:*

How was pet acquired?*

Pet Temperament:*

Known Allergies:*

Housing/Diet

Does your pet have access to the entire house?*

Yes
No

Is your pet:*

Indoor
Outdoor
Both
Caged

Describe your pet’s enclosure (type/size/location/objects inside):*

Is your pet supervised when out of its enclosure?*

Yes
No

What bedding/substrate is used?*

Temperature in enclosure (day and night):*

Humidity level:*

Type of lighting used:*

Is Lighting Timer Controlled?*

Yes
No

Do any other pets share enclosure?

How often is the enclosure sanitized?

What cleaning products are used for this?

Diet (brand and type of pellet/seed):*

Type of hay (if any):

Percentage of daily feed: %Pellets: %Hay %Fresh produce:

Other types of food offered / how often:

How long does it take for pet to eat each portion of food?

Dietary supplements:

Is fresh water provided daily:

History

Describe any medical problems:*

Current medications:*

Reason for today’s visit:*

For illness / injury, please list date first noticed, changes observed during problem, and methods of treatment:*

Fear Free Questionnaire

As Fear Free certified professionals, we want to make your visit to our hospital the best it can be for you and your pet. Please answer a few questions so we can take both you and your pet’s preferences for the visit into consideration

Which high reward treat would your pet prefer?

Number of people and pets in household:*

Your pet's complete records must be received before scheduling an appointment. Complete records means both vaccine information and medical chart. We will not offer shelter/rescue/AKC first free exam discounts unless the certificate is present at the first appointment.

Exotic Patient Information

Cancellations

Disclosure of Information

Electronic Consent

Pet Information

Housing/Diet

History

Fear Free Questionnaire

Emergency

Airvet

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