New Client Registration Form

  • Owner's Information

  • Co-Owner's Information

  • Please note: If you are providing this information, you are giving permission for us to contact you at work.

  • Referral Information

  • Pet Information

  • Dog
  • MM slash DD slash YYYY

  • Pet Medical History

  • MM slash DD slash YYYY

  • SMS Privacy Policy Agreement

  • Treatment Authorization & Financial Agreement

  • I hereby authorize the veterinarians at LaCrosse Animal Hospital to examine, prescribe for, and treat my animal(s). I also understand PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE. I have read and understood this policy, and I accept responsibility for all fees.
  • Clear Signature