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:
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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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    • Nancy J. MillerNancy J. Miller

      We’ve been bringing our fur babies here through many generations of kitties and personnel. They treat us and our cats as though we are family and friends. And who wouldn’t love a vet named Dr.Barker!?
      Last visit had our wonderful Casey Cat with a dental issue. As I’m in dentistry myself I was very pleased that my first encounter with Dr.Jesse Hermès had her explaining in detail what the issue was and the remedy she had to render. It was easy to tell she loves her work and our furry friends!
      Drs. Gass and Lafond are also high on my list of caring vets through the years of advice and kindness they’ve displayed caring for our furry companions. And the fact that their staff has been there for years is a testament to it being a great place to work! Thanks to you all and many Happy Purrs sent your way!

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    • Laurie Wishart WeberLaurie Wishart Weber

      A very friendly and caring staff. Have been going there for 25 years. My dogs have never hesitated about walking in the door there. Dr. Gass has been my vet and has gone thru many medical issues with us. I really appreciate the time he takes to personally call with results or to check up.

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    • Amy WiedAmy Wied

      The staff at Animal Hospital of Ashwaubenon are awesome! They cry with you when you have to say good bye to a faithful friend and celebrate with you when you add a new kitten to the family. I have had excellent care for my cats over the last 30 years.

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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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    • Sarah 'Adelbush' GiciusSarah 'Adelbush' Gicius

      We recently welcomed a new puppy into our family. Without hesitation we contacted Dr Gass to see our pet due to the compassionate, thorough care he gave our last dog. Dr Gass and his team have earned our complete trust — thank you for always going above and beyond! We highly recommend this clinic!

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    • Dawn Darrow-JelinskiDawn Darrow-Jelinski

      Everyone there is so kind and caring! Dr. LaFond is the best!! She knows how to handle my big dogs and I can talk to her about everything....she has always been there for us. I love her honesty when difficult decisions need to be made and appreciate her support ❤️.

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