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.

 Yes No

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.

  •  

  •  

  • pet cartoons

Website Designed & Developed by DVMelite | All Rights Reserved | Login

Facebook

YouTube