Registration Form

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

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

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?

Humane Organizations/Rescues

Property Management Office

Kennels & Pet Daycare

Groomers

Pet Insurance Companies

Pet Information

Pet's Name*

Species*

Breed*

Sex*

Color*

Date of Birth or Age*

Previous Veterinary Practice (if any)

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:*

Dogs:*

Exotics

Has your pet ever experienced a stressful or upsetting visit at a previous veterinary hospital?*

Yes
No

Does your pet exhibit stress during transport or car rides?*

Yes
No

Does your pet become stressed or anxious when introduced to new people and/or animals?*

Yes
No

Has your pet been prescribed a medication to help reduce fear, anxiety and/or stress during a veterinary hospital visit?*

Yes
No

Registration Form

Owner's Name

Co-owner's Name

Address

Informed Consent

Release of Medical Records

Pet Information

Fear Free Questionnaire

Emergency

Contact Us

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