Primary Owner Information
Name
(Required)
First
Last
Home Phone
Mobile Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
(Required)
Is there a secondary owner who has the authority to make all healthcare decisions regarding your pet(s)?
(Required)
Yes
No
Secondary Owner
First
Last
Secondary Owner Phone
Secondary Owner Email
How did you hear about us? Check all that apply.
(Required)
Sign/Drive By
Internet/Website/Google Search
Social media
Local business
Shelter
Referral from friend
Referral from other veterinary hospital
Other
Other
Do you have pet insurance?
(Required)
Yes
No
Which pet insurance do you have?
Are you interested in learning more about pet insurance?
Yes
No
Please download and review these Frequently Asked Questions about Onalaska Animal Hospital
Terms and Conditions
Consent
(Required)
I certify that I am at least 18 years of age and have the authority to make decisions on behalf of the patient(s)/pet(s) I register with Onalaska Animal Hospital.
Consent
Onalaska Animal Hospital has my permission to use video and photographs of me and/or my pet(s) publicly to promote its services in print and online media and presentations. I understand that no royalty, fee, or other compensation shall become payable to me for such use.
Consent
(Required)
I assume full financial responsibility for all charges incurred for the care and treatment of my pet(s) by Onalaska Animal Hospital. I understand that all the charges incurred in the treatment of my pet(s) will be paid in full at the time of discharge. OAH accepts cash, Visa, Mastercard, Discover, debit card, CareCredit, and check. OAH does not bill. I also understand that an estimate of the fees for veterinary services may be provided to me, and that I am encouraged to discuss all fees related to such care before services are rendered, and during my pet’s ongoing medical treatment. A deposit of 80% of the high end of the estimated fee is required prior to any care being provided. I understand that if collection action should become necessary for recovery of any monies due, I agree to pay any and all collection costs, court costs, and reasonable attorney fees.
Consent
(Required)
I consent to the release of all my pet(s) veterinary medical information from other veterinary providers to Onalaska Animal Hospital for the purpose of providing veterinary services to my pet(s).
Consent
(Required)
I have received the Frequently Asked Questions outlining the policies and procedures of Onalaska Animal Hospital.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY