New Client Registration

New Client Registration
Primary Owner Information
Name

First NameLast Name
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Is there a secondary owner who has the authority to make all healthcare decisions regarding your pet(s)?
Secondary Owner

First NameLast Name
Secondary Owner Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Owner Email
example@example.com
What was the primary reason you chose Onalaska Animal Hospital?
If you were referred by an existing OAH client or a friend, please provide their name(s) here.
If you saw us at a community event, please list which event here.
If you were referred to us by a rescue organization or humane society, please list which one here.
If you were referred to us by a specialist, please list the specialist/clinic here.
If you were referred to us by a breeder, please provide their name(s) here.
If you were referred to us by an emergency clinic, please list the which one here.
If you were referred by another veterinary hospital, please provide the name here.
If you were referred by an employer or coworker, please provide their name(s) here.
If you selected "Other", please let us know how you were referred.
Before scheduling your first appointment, where had you seen or heard about OAH?(Check all that apply)
Do you have pet insurance?
Which pet insurance do you have?
Are you interested in learning more about pet insurance?
Please download and review these Frequently Asked Questions about Onalaska Animal Hospital
Terms and Conditions
Check Box
Check Box (OPTIONAL)
Check Box

I assume full financial responsibility for all charges incurred for the care and treatment of my pet(s) by Onalaska Animal Hospital. I understand that all the charges incurred in the treatment of my pet(s) will be paid in full at the time of discharge. OAH accepts cash, Visa, Mastercard, Discover, debit card, CareCredit, and check. OAH does not bill. I also understand that an estimate of the fees for veterinary services may be provided to me, and that I am encouraged to discuss all fees related to such care before services are rendered, and during my pet’s ongoing medical treatment. A deposit of 80% of the high end of the estimated fee is required prior to any care being provided. I understand that if collection action should become necessary for recovery of any monies due, I agree to pay any and all collection costs, court costs, and reasonable attorney fees.
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Signature
Date

MonthDayYear
Date
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New Client Registration

Primary Owner Information

Please download and review these Frequently Asked Questions about Onalaska Animal Hospital

Terms and Conditions