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 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*
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*
Breed*
Sex*
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.
Reason for this Appointment*
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:*
Dogs:*
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.

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

Owner's Name

Co-owner's Name

Address

Informed Consent

Cancellation Policy:

Disclosure of Information

Pet Information

Fear Free Questionnaire

Emergency

Airvet

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