Mid Island Veterinary Practice Intake Form Logo
  • Mid Island Veterinary Practice

    706 New Dorp Lane, Staten Island, NY10306
  • Email: Midislandvetpractice@gmail.com

    Phone: (718)954-9582

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  • Pet Information

  • Current Veterinarian

  • Acknowledgment and Signature

  • I understand that payment is expected at the time services are rendered. I hereby authorize the staff of Mid Island Veterinary Practice to render any treatment which is deemed necessary to the health of my pet(s) while in custody of the practice.

    I understand that in the event of any unusual or emergency circumstances, the staff will make every attempt to contact me or my designated representatives before, if time permits, proceeding with the treatment.

    I understand that I will be financially responsible for all emergency procedures including the Estimate of Charges provided to me in person or over the telephone.

    I understand that a deposit is required for all pets admitted to the practice.

    I understand that if my account is not kept in good standing,it will be forwarded to a third-party collections agency, which may affect my credit rating.

    I understand that photos/videos may be taken of my pet for training or marketing purposes. These pictures/videos may be posted on our social media pages or our website

  • *I have read and agree to the statement above.

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