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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    • Sue BodillySue Bodilly

      We have been taking our "boys" Bronson and Blitz here for 25-plus years and have had excellent care, especially from Dr. Barker. He's the very best.

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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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    • Marlene Detampel- DerenneMarlene Detampel- Derenne

      love them helped me with my little girl. any????? were answered

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    • Karen PecardKaren Pecard

      I have been taking my cats to this clinic for as long as I can remember, and would never go elsewhere. They are very caring and compassionate people.

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    • Erin SteierErin Steier

      Animal Hospital of Ashwaubenon has taken care of my Australian shepherd Roland since he was 9 weeks old. They have been absolutely amazing. They remember us every time we come in and Roland absolutely loves visiting the vet.

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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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    • 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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