Join us on Saturday, Dec. 1st from 1-3 pm for beverages, snacks and Pet Pictures with Santa. ($5 donation to R.E.A.D.)
(All authorized Owners and Agents must be at least 18 years old):
Your Name[dynamictext your-name "CF7_GET key='your-name'" akismet:author]
Email[dynamictext your-email "CF7_GET key='your-email'" akismet:author_email]
Neutered / SpayedYesNo
Type of Pet
Pet Coat Color
How did you hear about us?
May we request records?YesNo
Other than the owners listed above, please specify any other persons to whom you give primary responsibility for the care of the patient.
I understand that my veterinarian will need to communicate with the owners, or someone designated by the owners, prior to the treatment of my pet(s) in order to obtain informed consent. For purposes of obtaining consent, I direct my veterinarian as follows: (Choose one)
Informed consent may be provided by:
Only the ownersBoth owners and Agents
I further acknowledge that no guarantee has been made as to the results that me be obtained. I understand that complications may arise which cannot be predicted and that I will be held financially responsiveness for any veterinary medical care necessitated by complications, in addition to those previously requested. In accordance with WI Stat 35.93, VE 7.02, this statement serves to inform you, the client, that some services may be provided by a veterinary student, certified veterinary technician or an unlicensed assistant.
Your signature for this agreement will be signed in person at our office on your first visit.