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:
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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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    • Adam DennehyAdam Dennehy

      I thought I was done crying until I got your flowers today. I cannot begin to tell you guys how thankful we are for all of you. You guys saved Bowser's life more than once, and gave him the painless passing he needed. Thank you so much for everything.

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    • Dave WilliquetteDave Williquette

      The best place for superior service and care!! The entire staff is excellent! Highly recommend!

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    • Rae HerdtRae Herdt

      They have the most caring staff! They make you and your pet feel so comfortable. To top it off they are very thorough explaining things and give you different options on the treatment and care for your pet.

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    • Forrest N Reeses HoganForrest N Reeses Hogan

      Top notch doctors and staff that care about my fur babies as much as I do. I've taken my pets to this clinic for over 30 years and wouldn't dream of taking them any where else. Whether it's a regular checkup, your puppy eating hostas or running into a trailer hitch, they are there to help you take care of your four-legged friends. Thank you, thank you, thank you! Joy & Tim Hogan, Reeses and Tripp.

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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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    • 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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    • 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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