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Client Registration Form
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
Afghanistan
Albania
Algeria
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Angola
Anguilla
Antarctica
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Korea, Republic of
Kuwait
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Nigeria
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Northern Mariana Islands
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Palestine, State of
Panama
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Pitcairn
Poland
Portugal
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Qatar
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Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
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Samoa
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Sint Maarten
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Sudan
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Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
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Virgin Islands, U.S.
Wallis and Futuna
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Yemen
Zambia
Zimbabwe
Ã…land Islands
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
No
Are you active duty or retired military, active police officer or firefighter?
(Required)
Yes
No
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
No
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.
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Date
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414-744-2240
3860 S Howell,
Milwaukee, WI 53207
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