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Veterinarians Muskego, Wisconsin | Muskego Animal Hospital

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New Client Registration Form

Home » New Client Registration Form

New Client Patient Information

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Date
Owner's Name
Name*
First Last
Do you currently have an appointment scheduled?*
- Yes
- No
Co-owner's Name & Contact #
Name
First Last
Phone
Address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day-Time Phone*
Work Phone*
Mobile Phone*
Email*
Enter Email Confirm Email
In case of EMERGENGY call*
When is the best time to call about your pet?
How did you become aware of our clinic?
- Clinic Sign
- Yellow Pages
- Internet Search / Website
- Referral
Referral (someone we may thank)
Pet Information
Pet's Name*
Species*
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Male Neutered?
- Yes
- No
Female Spayed
- Yes
- No
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Are there any current or past medical conditions of which we should be aware?
- Yes
- No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Is your pet on any medication or supplement?
- Yes
- No
If Yes, please list the medication or supplement
Does your pet have known drug/vaccine allergies?
- Yes
- No
If Yes, please list the allergies and reactions
Is your pet on a prescription diet?
- Yes
- No
If yes, please specify.
If your pet is a cat, does he/she go outdoors?
- Yes
- No
I agree to have my pet's records and/or vaccine history given to any facility needing information such as a boarding, training facility or Humane Society.
- Yes
- No
ALL FEES ARE DUE AND PAYABLE UPON COMPLETION OF SERVICE
I understand every effort will be made to achieve a sucessful outcome and to provide for all possible safety in hospital care and handling. I agree to pay fees for all services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated.*
- Yes
- No
Name*
First Last
Date*

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Muskego Animal Hospital

262-679-1200
fax: 262-679-3115
S80 W19055 Janesville Road
Muskego, WI 53150
Hours
Monday through Thursday: 8AM until 7PM
Friday 8AM-5PM
Saturday: 9AM until 12PM

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Wind Lake Animal Hospital

262-895-2600
fax: 262-895-4536
7835 S. Loomis Road
Wind Lake, WI 53185
Hours
Monday through Friday 8AM until 5PM
Saturday: 9AM until 12PM
*Evening appointments available by request*

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