New Client Form

Name*

E-mail*

I authorize Midland Animal Hospital to use my email address for purposes of email reminders and pet health information. (Your email address will not be transferred, sold, or shared with a third party.)*

Yes
No

Address*

State*

City*

Zip*

Home Phone*

Cell Phone*

Work Phone*

Preferred Method of Contact*

Home Phone
Cell Phone
Work Phone
Email
Text

Best Time to Reach You*

Occupation

Employer

Spouse Name

Spouse Phone

Emergency Contact Name*

Emergency Contact Number*

How did you learn of our practice? (check all that apply)*

Sign
Yellow Pages
Internet
Other
Personal Recommendation

Specify Other or Personal recommendation

To prevent the spread of infectious disease and parasites, all surgical, hospitalized, and boarded pets must be current on vaccines and free from internal and external parasites. Vaccine and parasite control will be provided by the doctor as needed at the cost of the owner.

By checking the box below, I understand that I am financially responsible for all charges incurred from medical treatment at this facility. I also understand that all professional fees are due at the time services are rendered. Please ask the receptionists, technicians, or doctor if you would like a written estimate.

I agree to the terms listed above.*

Yes

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Midland Animal Hospital Partners

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Midland Animal Hospital Contact and Hours

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