New Client Form
Full Name
*
First Name
Last Name
Phone Number
*
Primary
Format: (000) 000-0000.
Email Address
*
If you do not have an email address, type None.
Secondary Contact/Owner
First Name
Last Name
Secondary Contact Phone Number
Primary
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you are ever not able to be present for your pet to recieve veterinary care, you may authorize others to make medical decisions in your absence by indicating ther names below:
First Name
Last Name
Wisconsin law requires written informed consent to release your pet's health care records to certain third-party/non-owners (Wis. Stat. 453.075). Please indicate to whom you authorize us to release your pet's health records:
Other Veterinary Clinics/Hospitals
Kennels/Groomers/Day Care
Pet Insurance Companies
Rescue/Humane Society Organizations
Property Management Companies
Do you have your pet's medical history?
*
Yes, I have my pet's medical history.
No, my pet has never been to a vet before
No, I do not have my pet's medical history.
Please Upload any medical history documents:
Pet's name
*
Age
*
Species
*
Sex
*
Female
Female - spayed
Male
Male - Neutered
Unknown
Breed
*
Color
*
Any medical allergies?
*
History of adverse reactions after receiving vaccines (facial swelling, vomiting, diarrhea, Hives, Difficulty Breathing, collapsing)
*
Yes
No
Current medications/treatments
*
What best describes your pet's lifestyle?
*
Strictly Indoors
Primarily indoors with some outdoor activities
Primarily outdoors with some indoor activities
Strictly outdoors
Microchipped?
*
Yes
No
Reason for Visit
*
Does your pet show any reluctance to getting in the carrier or car?
*
Yes
No
How would you describe your pet's behavior during travel? (select all that apply)
*
Eager and Excited
Subdued/more quiet than usual
More vocal than usual
Does your pet do any of the following during travel? (select all that apply)
*
Pant
Hide
Poop
Tremble
Drool
Pee
Pace
Vomit
None of these
Are there any situations that your pet has tried to avoid or seemed to dislike in the past? (select all that apply)
*
Entering the Vet hospital
Going in to the exam room
Ear exam/cleaning
Unfamiliar people or animals
Nail trim
Being weighed
Having a rectal temperature taken
Other
Has your pet ever been prescribed any medications to help manage their fear or anxiety associated with the visit?
*
Yes
No
Do you think that your pet would benefit from medication to help manage their fear or anxiety around their upcoming vet visit?
*
Yes
No
Maybe
I acknowlege that this practice utilizes AI-assitated transcription services to document medical records accurately and efficiently. I consent to the use of AU for transcrition purposes.
I consent to the use of AI for transcription
I do NOT consent to the use of AU for transcription purposes
I further understand that payment is due at the time of service.
Signature
Submit
Should be Empty: