New Client Form

 
Your First Name:
Your Last Name:
Address:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Email:
Place of Employment:
Spouse Name:
Spouse Cell:
Spouse Employer:
Spouse Work Phone:
Referred By:

Informed consent medical records and information release

A. Wisconsin law requires written informed consent to release your pet’s health care records to
certain third-parties (non-owners). WisStat.453.075. Please indicate to whom you authorize us to
release your pet’s health care records:

Yes - Kennels and Groomers, Pet Daycares, Pet Insurance companies, other Veterinary Clinic / Hospitals, Rescue and Humane Organizations, ect...No - I do not give permission to release my pet’s health care records to the above organizations.

B. Wisconsin also requires written authorization from you for others (spouse, children, friends, pet
sitters, relatives, ect) to make medical decisions in your absence. Please list all applicable names.

C. Do we have permission to use photographs or radiographs of your pet in
clinic educational displays such as reminder cards, dental take home sheets, brochures, bulletin
boards. If yes, I agree not to file any claim for revenue or lawsuit for damages against this
veterinary practice with respect to display/release of this information.

YesNo

D. If you should ever need to find a new home for your pet, please understand that you will need to
submit written permission to us in order for records to be released to a new owner.

Yes - I certify that I am the client/owner listed above, I am at least eighteen (18) years of age, and this information is correct to the best of my knowledge.


Check to confirm submission.

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    • Jennie Herfort BrownJennie Herfort Brown

      Dr. Gass and staff are some of the nicest people and animal lovers around! You won't be disappointed - they truly care about our pets. ❤️❤️❤️❤️❤️

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    • Chad Stefanie BellinChad Stefanie Bellin

      We have been going to Animal Hospital of Ashwaubenon since we got our dog 16 years ago. They have been wonderful to our dog and to our family. About 5 years ago our dog became very sick and we thought we would have to put him down. Dr. Lafond saw us and started talking about her dog when it was sick. Due to talking to her we found out our dog was allergic to penicillin. He was taking a medication due to teeth cleaning which had penicillin in it. If it wasn’t for Dr. Lafond we believe we would have lost him! Due to old age we had to put our beloved Thumper down this past spring. The love and support we got from Dr. Lafond and the staff was more than what we could imagine! Thank you so much for taking such good care of Thumper!

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    • Ericka MeunierEricka Meunier

      We love the staff! They are the best at personal service. They answer every question with compassion & honesty. Always a smile or 3 when u walk in the door. They were very helpful & loving when our dog Wolfy passed away. They help in any way possible. They are always happy to see our new puppy Nala when we come in as well. :-)
      Bring all of your animal family members here. <3 They are the best!

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    • Diane KayDiane Kay

      Asti, Matti loved and now Ozzy Loves Dr. Barker, Julie M. And the rest of the staff! Thank you for all you have done in the past and do now for me and my fur babies, you are the best!

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    • Gabrielle BeaudryGabrielle Beaudry

      Went to the Animal Hospital of Ashwaubenon for the first time today for my dog's check up and for a few shots. Somewhat new to the area and couldn't be happier with the service and care they gave from the second I walked through the door to the second I walked out the door. Everyone in the office was extremely friendly and made a point to say hi to my dog and to ask me how our visit was going. Dr. Gass was excellent, very friendly and took time to explain to me the shots my dog would be getting since they were not typical ones we had the last place we lived. First visit but 100% recommend.

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    • Jessi OlpJessi Olp

      My cat Milo is horrible at the vets office. We hav even had vets not be able to get close enough to examine him in the past. Animal Hospital of Ashwaubenon has been great about going out of their way to make sure Milo gets the care he needs without getting as anxious as he usually does. The extra effort is greatly appreciated by Milo AND me!

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    • Amy TruckeyAmy Truckey

      Had a great experience today at Animal Hospital of Ashwaubenon. So glad we switched our dog to there! The staff was very friendly and caring.

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