New Patient Information

I hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges must be paid in full, at the time of release of the pet.

Please read the following:

I, the undersigned owner, agent of the owner, or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that I am eighteen (18) years of age
or over.

I consent to the examination/treatment of this pet by staff veterinarians at Kenosha Animal Hospital and I agree to pay for such services rendered.

I understand that an estimate of the costs for veterinary services may be provided to me if requested and that I am encouraged to discuss all fees related to such care before
services are rendered and during the pet’s ongoing medical treatment. I authorize the doctors and assistants to administer treatment as is considered therapeutically and/or
diagnostically necessary for this patient.

I agree that to assume full financial responsibility for the pet’s care and will provide payment via cash, credit card, debit card or Care Credit at the time service is received. I
understand this hospital does NOT provide in-house payment plans. There will be a 1% monthly late fee applied to any account not paid in full at the time of service.

RELEASE OF MEDICAL RECORDS

Wisconsin law requires written permission to release your pet’s health records to certain 3 rd parties(non-owners). Wis. Stat.453.075. Please indicate who you authorize us to release your pets health records to by checking YES or NO below.

INFORMED CONSENT

Are there any other persons (18 years or older) to whom you give primary responsibility for the care of your pets? (Authorized agents are not automatically entitled to make medical treatment decisions for your pet, unless you give permission below.) If yes, please list them in the order you wish us to contact them in the event that you or the co-owner are not available.  

My signature on this form indicates that I have read and fully understand the authorization of medical and/or surgical treatment, payments and release of information. I certify that I am the primary ownerand am at least eighteen (18) years of age and this information is correct to the best of my knowledge.