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Phone: 262-694-6515
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Registration 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.
Please complete this form prior to your first appointment. This will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.
Owner's Name
Name
*
First
Last
Co-owner's Name
Name
*
First
Last
Address
Main Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Primary phone#
*
Additional owner phone#
Primary cell#
Email
*
Enter Email
Confirm Email
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
Date
*
Month
1
2
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12
Day
1
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30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
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1982
1981
1980
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1928
1927
1926
1925
1924
1923
1922
1921
1920
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 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 authorize us to release your pet's health records to other veterinary clinics along with allowing us to request complete records from previous veterinary clinics?
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
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
*
First
Last
Pet Information
Pet's Name
*
Species
*
Dog
Cat
Rabbit
Bird
Reptile
Hedgehog
Ferret
Rat/Mouse
Chinchilla
Guinea Pig
Breed
*
Sex
*
Neutered Male
Spayed Female
Male
Female
Unknown
Color
*
Date of Birth or Age
*
Previous Veterinary Practice (if any)
*
Has your pet been vaccinated in the past year?
Yes
No
Please list any illnesses, injuries or surgeries your pet has had.
Is your pet on any medication or supplement?
Yes
No
If Yes, please list the medication or supplement
Does your pet have allergies to food, medications or vaccines?
Yes
No
If Yes, please list the allergies and reactions
Is your pet on a special diet?
Yes
No
If yes, please describe.
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?:
Cats:
*
Blank
Greenies
Pill Pockets-Chicken
Tuna Flavored Churus
Chicken Flavored Churus
Canned Cat Food
Turkey baby food
Chicken baby food
N/A
Dogs:
*
Blank
Sportmix treats
Cheerios
Pill Pockets-Hickory Smoke
Dehydrated chicken liver
Peanut Butter
Squeezee Cheese
Frozen chicken broth
Frozen canned pumpkin
N/A
Exotics
Number of people and pets in household:
*
Has your pet ever experienced a stressful or upsetting visit at a previous veterinary hospital?
*
Yes
No
Does your pet become stressed or anxious when introduced to new people and-or animals?
*
Yes
No
Does your pet exhibit stress or reluctance getting into the car or carrier, during transport, or arriving at the vet?
*
Yes
No
Has your pet been prescribed a medication to help reduce fear, anxiety and/or stress during a veterinary hospital visit?
*
Yes
No
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.
About Us
Contact
Our Veterinarians
Our Staff
Employment
Testimonials
Clients
What to Expect
Registration Form – Feline and Canine
Airvet App
Request an Appointment
Registration Form – Exotic Patient
Services
Physical Medicine
Anesthesia and Patient Monitoring
Avian Medicine
Breeding Services
Exotic Pet Medicine and Surgery
Health Screening Tests
Medical Services
Preventive Services
Surgical Services
Wellness and Vaccination Programs
Physical Medicine
Meet the Team
Initial Evaluation
Patient Track
Treatment Options
Pet Health
Fear Free
Pet Health Library
How-To Videos
Pet Health Checker
News
FDA Grain Free Diet Information
Rabbit Hemorrhagic Disease
Links
Payment Options