Pewaukee Veterinary Service - New Client Registration Form

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Arely is a magical wire-hair fox terrier. The terrier breed originated in England, so Arely has an Old English name which means courageous...
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*OWNER INFORMATION (Required Field)**
*Name :**
Spouse Name :
*Address :**
*City/State/Zip :**
Home Phone :
Cell Phone :
Secondary Cell Phone :
*E-Mail :**
Employer :
Employer Phone Number :
Other Employer :
Other Employer Phone Number :
Who may we thank for referring us to you :		Our Sign Website Online Search Newspaper Yellow Pages Breeder/Rescue Group Friend/Family Referral
AGENT INFORMATION
* Other than you and any additional owner(s) listed above, are there any other persons to whom you give primary responsibility for the care of your pet?		Yes No
* Please indicate if you would like to receive updates via text message. If yes, please indicate on which cell phone you would like to receive these reminders:		Yes, Cell Phone Yes, Secondary Cell Phone No, I would not like to receive updates via text message
Emergency Contact :
Emergency Phone :
Please list any special directions for our veterinarians/staff in the event we are unable to contact you, your co-owner, or authorized agents for consent in an emergency:

Professional fees are due at the time services are provided. We accept the following credit cards for your convenience: Visa, MasterCard and Discover. We offer Care Credit services for those wishing to apply.
Pewaukee Veterinary Service is pleased to provide the following services: General Health & Wellness Care • Injury & Illness • Sedation & General Dentistry • Orthopedics • Laparoscopic Surgery • Endoscopy • Ultrasound Digital Radiology • Diagnostics & Laboratory • Rehabilitation • Acupuncture Dog Day Care • Grooming • Boarding Services • Retail We are proud members of: American Animal Hospital Association American Veterinary Medical Association Wisconsin Veterinary Medical Association American Board of Veterinary Practitioners