New Client Form Step 1 of 333%Owner Name*Co-Owner NameOwner Birthdate*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address*Home NumberWork NumberCell Number*Co-Owner Work NumberCo-Owner Cell NumberName of Previous ClinicPhoneDo you have an appointment?*YesNoIf so, when is your appointment?How did you become aware of our clinic?*Whom may we thank?Place of EmploymentDriver License /State ID*Needed for Identification/Checks/Controlled SubstancesFirst PetSelect One:*DogCatBirdsReptilesSmall AnimalsPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PLymeLeptoBordatellaHeartworm Test Date of VaccinationsRabiesPRCFeLV/FIV Test Second PetSelect One:DogCatBirdsReptilesSmall AnimalsPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PLymeLeptoBordatellaHeartworm Test Date of VaccinationsRabiesPRCFeLV/FIV Test Third PetSelect One:DogCatBirdsReptilesSmall AnimalsPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PLymeLeptoBordatellaHeartworm Test Date of VaccinationsRabiesPRCFeLV/FIV Test Informed Consent Preauthorization FormThe state of Wisconsin Department of Regulation and Licensing and the Veterinary Examining Board have established new guidelines on veterinary practice, defined as Informed Consent. These guidelines require an owner to give informed consent prior to performing any medical or surgical procedure. If you want to allow anyone else to be able to present your pet for veterinary care, you must list them as an authorized care giver. This includes any co-owners, family members, friends or roommates you want to allow to make decisions about your pet. Children under the age of 18 cannot legally give consent or authorize treatment, however the owner can include them on this form to give them prior consent, allowing them to make minor decisions, like vaccinations, blood work, radiographs, and medications. Without proper authorization, anyone else bringing in the pet cannot request services, and the owner must be contacted before we can proceed.Please allow the following people to make Informed Consent decisions on my behalf:NameRelationshipMonetary LimitPet I/we hereby authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures.Type SignatureDate Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
