Registration Form – Exotic Patient

Welcome to Care Animal Hospital of Pleasant Prairie. We appreciate your interest in our services and look forward to meeting your pet. A completed registration form and your pet's complete records (both vaccine information and medical chart) are require. This helps to give us valuable insight in providing optimal care for your pet(s). Once all is received our staff will then contact you to schedule your pet’s appointment. The required sections have a red * asterisk.

Owner's Name
Name*
First Last
Phone Number*
Please specify if phone number is*
- Mobile
- Landline
Additional Phone Number
Please specify if phone number is
- Mobile
- Landline
Email*
Enter Email Confirm Email
Co-Owner's Name
Name*
First Last
Phone Number*
Please specify if phone number is*
- Mobile
- Landline
Additional Phone Number
Please specify if phone number is
- Mobile
- Landline
Email
Enter Email Confirm Email
Address
Main Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Whom may we thank for the referral?
Informed Consent
A. (Who can bring my pet in for treatment) Other than you and the co-owner, are there any other persons (18 years or older) to whom you give primary responsibility for the care of your pets? (Authorized agents are not automatically entitled to make medical treatment decisions for your pet, unless you give permission in section B). If yes, please list them in the order you wish us to contact them in the event that you or the co-owner is not available.*
- Yes, the additional agents are listed below
- No, there are no additional agents
Authorized Owner’s Agent #1
First Last
Phone
Authorized Owner’s Agent #2
First Last
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
Cancellation Policy
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)*
If intact female, any litters or clutches?
- Yes
- No
If yes, any complications?
Length of time in current household:*
How was pet acquired?*
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):*
Please include at least one picture of your pet's enclosure.
This is to help us visualize how the space is allocated for the various activities that your pet may perform on a daily basis (e.g. hiding, basking, soaking, feeding, playing, etc.). If you utilize lights (UVB, heat lamps, and/or traditional lighting), under heat mats, misting systems, etc., it is helpful to see where those are located in terms of where your pet likes to spend the majority of their time. It also helps us to see how you are monitoring the temperature and humidity and how you are feeding. Knowing where the enclosure is within or outside of the house and where it is in relation to other pet enclosures that you may have, is also useful. Thank you for helping us provide the best care that we can for your pet!
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:
How often is fresh water provided?*
History
Describe any medical problems:*
Reason for this Appointment*
Current medications:*
For illness / injury, please list date first noticed, changes observed during problem, and methods of treatment:*
Fear Free
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 consider both your and your pet’s preferences for the visit. Please bring a special treat from home that we can give your pet during the appointment to create a positive experience.
Which high reward treat would your pet prefer?*
Pet Temperament:*
Number of people and pets in household:*
Medical Records
Your pet's complete records must be received before scheduling an appointment.
Drop files here or
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.

Emergency

In case of an EMERGENCY after hours, you can contact us on our pager for a phone consultation. The number for the pager can be found at the bottom of one of your receipts.

If we are unavailable, you can contact:

Veterinary Specialty Center, 2501 Waukegan Road, Bannockburn, IL, 60015, (847) 459-7535

Wisconsin Veterinary Referral Center, 1123 58th Avenue, Somers, WI, 53144, (262) 553-9223

Premier Veterinary Group, 1810 Belvidere Road, Grayslake, IL, 60030, (847) 548-5300

BluePearl Pet Hospital, 2100 W Silver Spring Drive, Glendale, WI, 53209, (414) 540-6710

Exotic Patient Information

Owner's Name

Co-Owner's Name

Address

Informed Consent

Cancellation Policy

Disclosure of Information

Electronic Consent

Pet Information

Housing/Diet

History

Fear Free

Medical Records

Emergency

Airvet

Contact Us

Hours of Operation