Client Update Form | Mayfair Animal Wellness Clinic in Wauwatosa, WI

Thank you for giving us the opportunity to care for your pet(s). Please fill out the below information so we can make sure we have the most recent and accurate information.

Client Information

Name*

First

Last

Spouse's Name

Address*

Street Address

Address Line 2

City

State

ZIP Code

Phone*

Spouse's Phone

Best time to reach you*

Best way to reach you*

Email*

In case we cannot reach you regarding your animal, we need contact information for a close friend or relative.

Name*

Relationship*

Phone*

Does this close friend or relative have permission to make medical decisions on your behalf?*

Yes

How did you become aware of our clinic?*

Whom may we thank?*

If Other, please specify*

Pet Information

Pet's Name*

Breed*

Date of Birth*

Color*

Sex*

Male

Neutered Male

Female

Spayed Female

Do you want to add a second pet?*

Yes

Pet 2 Information

Pet's Name*

Breed*

Date of Birth*

Color*

Sex*

Male

Neutered Male

Female

Spayed Female

Do you want to add a third pet?*

Yes

Pet 3 Information

Pet's Name*

Breed*

Date of Birth*

Color*

Sex*

Male

Neutered Male

Female

Spayed Female

Additional Information

Our pet(s) is/are*

Member of Our Family

Child’s Pet

Backyard Pet

Any previous serious illness or surgeries*

Any Allergies to vaccinations or medications?*

If your pet has previously been seen by another veterinarian, please provide pertinent records so that we may have all necessary information regarding your pet(s).

Previous Veterinarian*

Phone*

PHOTO RELEASE

I grant Mayfair Animal Wellness Clinic and its employee(s)
permission to take photographs and/or video of me and/or my pet(s). I agree that
such photos, videos, or stories including me and/or my pet with or without names and
for any lawful purpose, including for example such purposes as social media,
publicity, advertising, and other web content.

Photo Release – Social Media Consent*

Yes, I consent

No, I do not consent

Printed Name*

Signature*

Date*

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Comments

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