Testing First Day Checklist Pet Name:General Information: How long have you owned your pet?If adopted, do you have any knowledge of your pet's past history?Spayed or neutered?YesNoIf so, when?If so, when?Health: Feeling good and healthy? Yes No If no, what restrictions need to be placed on your pet's activities or movements?Anything contagious?YesNoCleared by vet?YesNoDoes your pet have any allergies?Behavior: Has this pet ever been in a kennel crate?YesNoHas this pet ever been in a kennel crate?YesNoIf yes, were they OK in the kennel?YesNoIs your pet food- or bone-possessive toward people or other dogs?YesNoHas your pet ever climbed/jumped a fence?YesNoIs your pet friendly with strangers?YesNoIs your pet friendly with other pets?YesNoIs your pet shy or aggressive?YesNoVeterinarian:AllergiesAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country PhoneEmergency contact:Relation:PhoneCertificate for Care I Grant Milwaukee Walk in Vet Clinic and/or its selected agents full power of decision concerning the care and well being of my pet.Should any medical condition arise, it is agreed that MWVC or its selected agent can, and will, make any needed decision concerning medical treatment and choice of caregiver up to $ .($500 suggested)SignatureDate Print Name:I further certify that this pet has not harmed or shown aggressive or threatening behavior towards any person or any other pet. Vaccinations: Distemper Group expiration:Rabies expiration:Bordetella expiration:Signature of owner —————————————————- Application for Enrollment Owner's information: Name:Address Street Address City State / Province / Region ZIP / Postal Code Home Phone:Work Phone:Cell Phone:Email Employer:Work phoneCell phoneWho referred you to us?Pet's Information: Name:Breed:Sex:Neutered:Age:Date of birth: Weight:Brand of food:Amount of food:Feedings per daySpecial needs (medications, etc.): —————————————————- Boarding Agreement 1. I understand that I am solely responsible for any injury incurred to my pet(s) or any damages caused by my pet(s) while he/she is/are attending Milwaukee Walk in Vet Clinic (WIS STATE. SECTION 174.02). 2. I further understand and agree that in admitting my pet(s) to Milwaukee Walk in Vet Clinic, they have relied on my representation that my pet(s) have not harmed or shown aggressive or threatening behavior towards any person of any other pet. 3. I further understand and agree that Milwaukee Walk in and their staff will not be liable for any problems that develop provided reasonable care and precautions are followed, and I hereby release them of any liability of any kind whatsoever arising from any pet(s) attendance and participation at Milwaukee walk in Vet Clinic . 4. I further understand and agree that any problem that develops with my pet(s) will be treated as deemed best by the staff of Milwaukee Walk in Vet Clinic , in their sole discretions, and that I assume full financial responsibility for any and all expenses involved. Reasonable efforts to reach you will be made before any medical decisions are made. 5. I understand and agree to have my pet engage in group play with other boarded pets of compatible energy level, and similar behavior. I understand the risks involved in such play. OPT OUT PROVISION: by initialing hereI am advising MWVC not to allow my pet to engage in group play and I understand this might limit my pet's playtime while boarded. 6. If a pet is not picked up within 48 hours of the time indicated for pick up when the pet is dropped off, or if there is no verbal telephone agreement, MWVC will send written notice to you of the failure to pick up your pet. If following said notice any pet remains at MWVC for greater than 21 days without payment of boarding fees, MWVC reserves the right to deem the pet abandoned and transfer the pet to an animal shelter or otherwise place the animal. MWVC will not be liable for the welfare of said pet following transfer from the MWVC boarding facility. Vaccines: All pets must have up-to-date vaccinations. Owners must submit written verification from their Veterinarian that their pets have the current Distemper group, Rabies, and Bordetella. Bordetella must be updated every six months. The Oral Bordetella Vaccine is available at our Facilities, if needed. Application: All pets must have a complete, up-to-date and approved application on file. Collars: All collars must have proper identification Reservations: Please note: Pick-ups and drop-offs scheduled by appointment only. Scheduled and non scheduled pick-ups and drop-offs outside of regular hours, will add $1 for every minute, to your bill. You must call ahead if you are to be late.Food is provided by the owner if food is provided by MWVC there will be a charge of $2-$7 per meal depending on amount and type of food needed Medication is provided by the owner with all current direction accompanying the prescriptions themselves Bowls and blankets are provided by MWVC to help prevent lost items. Please let staff no about any needs your pet will outside of normal care. | certify that I have read and understand all the rules and regulations set forth and that I have read and understand this agreement, I agree to abide by the rules and regulations and accept all the terms, conditions, and statements of this agreement Signature of Owner:Date This veterinary clinic is a walk-in clinic with a No Hidden Price policy.
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