Informed Consent Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together. So that we can have the most up to date information, please complete this form prior to your pet’s appointment. The required sections have a red * asterisk.

Owner Info
Name*
First Last
Co-Owner Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Co-Owner Phone*
Primary Cell*
Email*
Who/What may we thank for the referral?
Pet Info
Name*
Species*
Breed*
Sex*
Color*
Date of Birth or Age*
Consent*
I agree to the informed consent policy.
Cancellation Policy:
In order to help all of our patients, we require a 24 HR cancellation notice. If you are more than 7 minutes late for your appointment, we will reschedule for another time. Please initial on the line below.*

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.
Additional Agents*
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
Consent*
I agree to the below stated.
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*
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?*
Humane Organizations/Rescues*
Property Management Office*
Kennels & Pet Daycare*
Groomers*
Pet Insurance Companies*

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Informed Consent Form

Owner Info

Pet Info

Release of Medical Records

Emergency

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