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Client Registration Form

Owner's Name(Required)

Owner's Birthday(Required)

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone Number(Required)

Email(Required)

Co-Owner Name

Co-Owner Phone Number

Other Authorized Person(s) you would like to add to your chart (must be at least 18 years old)

Name

Phone

Name

Phone

Please answer the following questions:

Where did you go for previous veterinarian care

May we release your records to any third party?(Required)

Yes

No, I wish to be contacted first.

Note: A third party may be a groomer, doggy daycare facility, other animal hospitals/referral centers or rescues.

Are you a senior citizen? (65 or older)(Required)

Yes

Are you active duty or retired military, active police officer or firefighter?(Required)

Yes

Photo Consent: We love to take photos of our patients for educational purposes, marketing, social media, our website and medical charting reasons. No personal information will be used without your permission. Do you consent to allowing us to take and/or use photos of your pet for the above described purposes?(Required)

Yes

Authorization for treatment:
I hereby authorize the veterinarian(s) of St. Francis Animal Hospital to examine, prescribe, treat and perform procedures for my pets as medically deemed necessary and authorized by me. I understand that I am responsible for all costs incurred and that payment is due at the time of service. I further acknowledge that no guarantee has been made as to the results that may be obtained. I understand that complications may arise which cannot be predicted and that I will be held financially responsible for any veterinary medical care necessitated by complications.

Signature(Required)

Date(Required)

Client Registration Form

Get in touch

414-744-2240

Business Hours

414-744-2240