Welcome to Mid North Animal Hospital  

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client Registration

Name & Email (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
E-Mail Address (required) :
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
Please provide your Social Security Number and/or Driver's License
Social Security Number

Driver's License Number

Emergency Contact Phone Number
Phone TypePhone Number
Relationship of Emergency Contact to Owner

Your Pet's Information (Please use one online form per pet)
Pet's Name (required)

Age: Years, Months

Species (required) :
Sex: (required)
Male
Female
Unknown

Neutered/Spayed (required)
Neutered
Spayed
Intact
Unknown

Breed: (required)

Markings / Color of Pet (required)

Where did you obtain your pet ?
Breeder
Rescue
Pet Store
Other

Are your pet's vaccines current ?
Yes
No
Uncertain

What diet is your pet currently eating?

Please list any meications that your pet is currently taking

Do you have pets medical records?
Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
PROFESSIONAL FEES ARE EXPECTED TO BE PAID AT THE TIME SERVICES ARE PERFORMED. In admitting my pet for diagnostics, treatment, or surgery, I authorize the veterinarians of Mid North Animal Hospital and their support staff to administer such treatment and or perform such diagnostic or surgical procedures as deemed necessary. It is understood that an estimate of charges will be given for services. No guarantee or assitance an be made to the results that may be obtained. Further, I realize that these charges may exceed a given estimate if complication arises. I understand that I will be contacted prior to treatment, if possible, should complications occur. I also agree to pay Mid North Animal Hospital an agreed upon monthly payment amount if the balance in full is not paid at the time services are performed. If account goes delinquent: no payment in 60 days, the account will be assessed a 2.00% billing fee of outstanding balance (minimum $3..00) monthly. I furgher agree if the account is tranferred to collection, I will be responsible for all cost necessary to collect this balance including colletion fees, attorney fee, court cost, and filing fee. If a check is returned non-sufficient funds, a minimum charge of $25.00 will be added to the amount owed.
I have read this statement and - (required)
I Agree
I Disagree


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