Wauwatosa Vet New Client Form1

New Client & Patient Information Form
Primary Owner's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Work/Alternate Phone Number
Please enter a valid phone number.
E-mail*
example@example.com
Co-Owner's Name (if applicable)

First NameLast Name
Co-Owner's Phone Number
Please enter a valid phone number.
In case of Emergency, please call:
Please enter a valid phone number.
Name & Location of Previous Veterinary Clinic
How did you hear about us?*
Other*
If you were referred by one of our current clients, please tell us their name so we can thank them.
We love showing off our adorable patients! Do we have permission to use your pet's photo on social media, on our website or in marketing materials?*
I, the Owner listed above, agree to pay for all services at the time they are rendered and understand that I am entitled to ask for a written estimate of fees for any medications, treatments, diagnostics, surgery or hospitalization prior to services being provided.*

Yes, I agree.
We accept Cash, Check, Visa, Mastercard, Discover, American Express and Care Credit. A $31.50 return fee will apply for all returned/NSF checks.
Vaccine Information & Consent Info

Please note our recommended vaccines for MOST healthy pets:

Dogs:

Cats:

Rabies

Distemper/Parvovirus

Tracheobronchitis/Bordetella

Leptospirosis

Lyme Disease

Rabies

Rhinotracheitis, Calicivirus, and Panleukopenia (FVRCP)

Immunizing your pet is an important part of your pet’s long-term healthcare plan, and in most cases will provide protection against an illness that could be life threatening. Although most pets do not react adversely to a vaccination, some have had allergic or other systemic reactions after receiving a vaccine.

Your decision to vaccinate your pet should not be taken lightly. A decision should only come after your pet’s age and the risk of exposure to disease are considered by you and your veterinarian. Vaccinations given at the appropriate age and at the appropriate intervals are generally very safe though and will greatly benefit your pet and potentially extend their life by preventing illness.

I have read the above information and I am aware that there are risks associated with failure to vaccinate my pet as well as potential side effects associated with receiving the vaccination. By signing this consent form, I authorize the administration of the vaccines recommended by my veterinarian.*

Yes, I understand.
Pet #1 Information
Name of Pet #1*
Species*
Breed*
Color*
Date of Birth*

MonthDayYear
Date
Sex*
Is Your Pet Spayed/Neutered?*

YesNo
Is Your Pet Microchipped?*

YesNoNot Sure
Medications / Supplements Your Pet is Currently Taking

NoneOther
Drug Allergies / Food Sensitivities

NoneOther
Diet / Food Currently Eating
Major Medical Problems / Chronic Health Conditions

NoneOther
Behavior Issues / Concerns

NoneOther
Is Your Pet on Year-Round Heartworm Prevention?
Is Your Pet on Year-Round Flea & Tick Prevention?
Approximate Date of Last Vet Visit
Any Other Issues / Concerns That We Should Know About?
Please have any prior records emailed to us at least 1 business days prior to your pet's first appointment to records.tosavet@gmail.com. This will help us prepare for your pet's upcoming visit. If you have any questions, please call us at 414-475-5155. We look forward to seeing you soon!

If you have any additional pets, please complete their information in the sections below.
Pet #2 Information
Name of Pet #2
Species
Breed
Color
Date of Birth

MonthDayYear
Date
Sex
Is Your Pet Spayed/Neutered?

YesNo
Is Your Pet Microchipped?

YesNoNot Sure
Medications / Supplements Your Pet is Currently Taking

NoneOther
Drug Allergies / Food Sensitivities

NoneOther
Diet / Food Currently Eating
Major Medical Problems / Chronic Health Conditions

NoneOther
Behavior Issues / Concerns

NoneOther
Is Your Pet on Year-Round Heartworm Prevention?
Is Your Pet on Year-Round Flea & Tick Prevention?
Approximate Date of Last Vet Visit
Any Other Issues / Concerns That We Should Know About?
Pet #3 Information
Name of Pet #3
Species
Breed
Color
Date of Birth

MonthDayYear
Date
Sex
Is Your Pet Spayed/Neutered?

YesNo
Is Your Pet Microchipped?

YesNoNot Sure
Medications / Supplements Your Pet is Currently Taking

NoneOther
Drug Allergies / Food Sensitivities

NoneOther
Diet / Food Currently Eating
Major Medical Problems / Chronic Health Conditions

NoneOther
Behavior Issues / Concerns

NoneOther
Is Your Pet on Year-Round Heartworm Prevention?
Is Your Pet on Year-Round Flea & Tick Prevention?
Approximate Date of Last Vet Visit
Any Other Issues / Concerns That We Should Know About?
Should be Empty:

New Client & Patient Information Form

We accept Cash, Check, Visa, Mastercard, Discover, American Express and Care Credit. A $31.50 return fee will apply for all returned/NSF checks.

Vaccine Information & Consent Info

Pet #1 Information

Please have any prior records emailed to us at least 1 business days prior to your pet's first appointment to records.tosavet@gmail.com. This will help us prepare for your pet's upcoming visit. If you have any questions, please call us at 414-475-5155. We look forward to seeing you soon!

Pet #2 Information

Pet #3 Information