New Client/Patient Online Registration
For your convenience:  Please use the form below to register your pet and use the appointment request e-form to request an appointment, if you wish.  Feel free to contact us with questions by phone at (262) 652-4266 or in person at any time.

If your pet has received veterinary care elsewhere in the past:   Please try to bring a copy of his/her medical records to your first appointment or ask your prior veterinarian to fax or email us the records.  Most veterinarians are happy to fax records -- just give them our phone number and they will take care of the rest.  If you need our assistance in getting records, just let us know and we'll help!

Before completing this online form, please read our Hospital Policies page. 
Don't miss our online coupon!

Before your appointment check out our Preparing Your Pet For An Appointment page for tips.

Form - Online New Client Form

Owner (required)
First Name (required)
Last Name (required)
Co-Owner
First Name
Last Name
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Home Phone (required)
Phone TypePhone Number (required)
Other Phone
Phone TypePhone Number
Employer

May we contact you at work?
Yes
No

E-Mail Address (We will not sell or distribute in any way. See our privacy policy.) :
Secondary E-Mail Address :
Preferred Reminder Method: (required)
Email
Postal Mail

Emergency Contact (required)
First Name (required)
Last Name (required)
Emergency Contact Phone (required)
Phone TypePhone Number (required)
Pet's Name (required)

Pet's Date of Birth or Age (required)

Species: (required)
Dog
Cat
Ferret
Rabbit
Guinea Pig
Bird
Other (please specify)

Other Species:

Breed: (required)

Color: (required)

Sex: (required)
Neutered Male
Spayed Female
Intact Male
Intact Female
Unknown

Does your pet have any drug allergies? (required)
(If yes, please name drug below in special requests or conditions)
Yes
No

Do you have your pets medical records? (required)
Yes
No

Are your pets vaccines current? (required)
Yes
No

Are there medical records at another veterinary practice? (required)
Yes
No

Name of former veterinary practice

City/State of former veterinary practice

Phone Number of former veterinary practice

May we request a transfer of records?
Yes
No

Would you like us to call you for your appointment? (required)
Yes
No

Reasons or conditions that prompted your visit (required)

Special requests or conditions

Please list any additional pets here

How did you hear about us? (required)
(Please list name below so we can give proper thank you.)
Yellow Pages
Drive-by/Sign
Mailing
Internet
Public Event
Media/TV/Radio/Newspaper
Have Been Here Before
Petco
PetSmart
Safe Harbor H.S.
Countryside H.S.
Kindred Kitties
Referred by Friend
Referred by Shelter/Groomer/Other (please give business name)

Referred by:

Please read:
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet(s) while in the care of Wolf Merrick Animal Hospital. I understand that payment is due and payable in full, at the time of services. I have read and understand the Wolf Merrick Animal Hospital Payment Policies.
I have read this statement and - (required)
I Agree
I Disagree


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