New Client / Patient Form in Ripon, WI | Associated Veterinary Clinic

Comments

This field is for validation purposes and should be left unchanged.

Please provide us with the following information about yourself and your pet:

YOUR NAME*

PLEASE LIST ALL PERSONS AUTHORIZED TO REQUEST SERVICES FOR THIS PET:

Address*

Street Address Address Line 2 City State ZIP Code

PHONE NUMBER #1*

THIS NUMBER BELONGS TO:

PHONE NUMBER #2

THIS NUMBER BELONGS TO:

PHONE NUMBER TO RECEIVE TEXT REMINDERS ON

EMAIL ADDRESS FOR RECEIVING EMAIL REMINDERS*

PLACE OF EMPLOYMENT AND PHONE

NAME OF PET BEING SEEN TODAY

PET

Canine
Feline

BREED

COLOR

SEX

Female
Male

IS THE PET SPAYED OR NEUTERED?

PET’S BIRTHDATE

(if known, if not, guess)

Do you currently own any other pets? (Please list)

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 release of your records to:

Other veterinary clinics/hospitals
Rescue/Humane society organizations
Kennels/groomers/pet daycare
Property Management Companies
Pet Insurance Companies
Other

Other Authorization Release

Payment is needed at the time of service. How will you be settling your account today?*

Cash
Check
Credit card

CAPTCHA

Consent*

I understand there will be interest of 1% per month on all unpaid balances. Failure to make a payment within 30 days of services will lead to the account being turned over to our collection agency and a termination of all veterinary services from our clinic.

Client Signature*

Date*

Associated Veterinary Clinic

New Client / Patient Form

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New Client / Patient Form

Contact Us

Appointments

Leave us a review

This site uses tracking technologies

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