American Veterinary Hospital

(414) 304-1818

2735 W Rawson Ave, Franklin, WI 53132

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New Patient/Client Registration Form

Owner’s Information

Name*
Address*
MM slash DD slash YYYY
Is it
Is it
Is it
How did you find out about our practice?*
What Social Media Platforms do you use?*

Pet’s Information

(applies to pets adopted from Woof Gang Rescue)
Microchip

Medical Information

Do we have your permission to collect records?*
Are there any current or past medical conditions we should be aware of?*
Are there any other pets in the home?*
Do you have another pet you would like to register with our practice today?*

2nd Pet

(applies to pets adopted from Woof Gang Rescue)
Microchip

Medical Information

Do we have your permission to collect records?*
Are there any current or past medical conditions we should be aware of?*
Are there any other pets in the home?*

Photo Consent:

We love social media! Do we have your permission to share your pet(s)’ image/video/story on social media, our website & other forms of related media? Your name and personal information will never be shared*

Pet Health Savings Plan

Say Goodbye to full price with our In-House Savings Plan! Not only will you save 20% on every invoice at every visit, your pet will also receive a FREE Rabies vaccine!

Treatment Consent

Upon signing this agreement, I certify I am the Owner/Authorized Agent of the above pet(s) and have authorization to consent to treatment if and when needed. I authorize the American Veterinary Hospital to examine, prescribe for and/or treat the above pet(s).*
I recognize that financial concerns should be discussed PRIOR to exams & treatment.*
I understand I am entitled to ask for and be provided with a written estimate of fees regarding services and/or products prior to services being performed.*
I assume full responsibility for all charges incurred and understand these incurred charges are to be paid, IN FULL, at the time the services are rendered.*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

American Veterinary Hospital

2735 W Rawson Ave
Franklin, WI 53132

(414) 304-1818

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