New Client

Owner Information

(All authorized Owners and Agents must be at least 18 years old):

Your Name[dynamictext your-name "CF7_GET key='your-name'" akismet:author]
Your Address
Primary Phone
Work Phone
Email[dynamictext your-email "CF7_GET key='your-email'" akismet:author_email]

Co-Owner Information

Name
Phone

Patient Information

Pet Name
Pet Age
Pet SexMaleFemale
Neutered / SpayedYesNo
Type of Pet
Pet Breed
Pet Coat Color

Referral

How did you hear about us?
Previous Clinic
May we request records?YesNo

Agent Information

Other than the owners listed above, please specify any other persons to whom you give primary responsibility for the care of the patient.

Agent 1
Name
Relationship
Phone

Informed Consent

I understand that my veterinarian will need to communicate with the owners, or someone designated by the owners, prior to the treatment of my pet(s) in order to obtain informed consent. For purposes of obtaining consent, I direct my veterinarian as follows: (Choose one)

Informed consent may be provided by:
Only the ownersBoth owners and Agents

I further acknowledge that no guarantee has been made as to the results that me be obtained. I understand that complications may arise which cannot be predicted and that I will be held financially responsiveness for any veterinary medical care necessitated by complications, in addition to those previously requested. In accordance with WI Stat 35.93, VE 7.02, this statement serves to inform you, the client, that some services may be provided by a veterinary student, certified veterinary technician or an unlicensed assistant.

Your signature for this agreement will be signed in person at our office on your first visit.

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