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

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

Date

Release of Medical Records

A. Wisconsin law requires written permission to release your pet's health records to certain third-parties (non-owners). Wis.Stat.453.075. Please indicate to whom you authorize us to release your pet's health records. Do you want us to release your pet's health records to other Veterinary Clinics?

Please list any and all Veterinarians, Humane Organizations/Rescues, Property Management Office Kennels & Pet Daycare, Groomers, Pet Insurance Companies, etc that you authorize us to release your pet's medical records to.

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:*

Yes
No

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?

How many people in the household?

Exotic Patient Information

Electronic Consent

Release of Medical Records

Pet Information

Housing/Diet

History

Fear Free Questionnaire

Emergency

Airvet

Contact Us

Hours of Operation