New Client E-Form + Hospital Policies

Please be advised: A face covering/mask is no longer required to enter.

If you wish to remain in your vehicle for the duration of the appointment we are asking that you please call us upon your arrival to check-in, if you do not have a phone please see the front desk to check-in.

Sign up for our Pet Portal here in order to request prescription refills online or on-the-go by using our app MyPetsWellness.

New Client Information

Owner's Name*

First NameLast Name

Spouse/Other

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone*

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

E-mail address*

example@example.com

Emergency Contact

First NameLast Name

Emergency Contact Phone

Please enter a valid phone number.

How did you learn of Midwest Veterinary Hospital?

Pet's Name*

Species*

Breed*

Color*

Age or Date of Birth*

Sex*

Neutered or Spayed*

Pet's Name

Species

Breed

Color

Age or Date of Birth

Sex

Neutered or Spayed

Pet's Name

Species

Breed

Color

Age or Date of Birth

Sex

Neutered or Spayed

Appointment Date:

Date

Is your pet(s) currently taking any medications?*

Does your pet(s) have any known allergies?*

Is there any significant medical history that we should know?*

Please upload vaccination record(s) and/or any significant medical history

If unable to upload history please email the record to reception.mwvh@gmail.com or bring it with you to your upcoming appointment

Method of Payment (check one or more)*

CashCheckDebit/Credit Card (American Express not accepted)CareCredit (speak with reception for more info)

I understand every effort will be made to achieve successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed above. Furthermore, I agree to pay fees for all services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for reasonable costs of collection, attorney fees, and court costs in the event that collection efforts become necessary. I agree that the venue of this action will be in the county where the hospital is located. I understand that veterinary services is provided during nighttime hours, as necessary in the judgment of the veterinarian in charge. Continuous presence of qualified personnel may not be provided.

Signature*

Date*

Date

Financial Policy

We are pleased you selected us to provide the highest quality of veterinary care for your pet. We will do our best to earn your continued business. Communication is important; therefore, we feel it is important for you to know our payment policy. Please carefully read the information below to familiarize yourself with our policy. If you have questions, please ask one of the receptionists. Should questions arise after your departure from MWVH, please phone our office at (405) 732-4505.

1. Full payment is expected upon discharge of your pet/animal from the hospital.

2. Clients are required to pay an initial payment/deposit equal to 50% of the high end of the estimated charge upon admitting their pet/animal to MWVH.

3. Acceptable forms of payment are cash, personal checks (state law prohibits acceptance of 2-party checks), Visa, MasterCard, Discover or CareCredit (for CareCredit, see #7).

4. Pet insurance is accepted. However, MWVH will not assume responsibility for filing claims or collecting from an insurance company. The client is responsible for paying MWVH and then filing for reimbursement from their insurance company.

5. Written estimates from the doctor are available upon request for patients requiring surgery, hospitalizations and/or more costly outpatient procedures. This estimate will include a brief summary of procedures and a range of total estimated cost.

6. At times it may become necessary to conduct additional procedures and treatments that were not anticipated upon initial examination and diagnosis. Should this become necessary, you will be notified. An additional deposit may be required unless the additional procedure and treatment were performed due to a potentially life-threatening scenario.

7. New clients or clients not meeting the requirements outlined above, may make an application to CareCredit for a line-of-credit. CareCredit is an independent financial agency and credit is extended only upon approved credit check. Depending on the amount borrowed, the loan is usually interest free if repaid within 12 months. Repayment plans longer than 12 months are charged an annual percentage rate. Billing and payments are handled entirely through CareCredit. You may complete a CareCredit application and request we submit it for you, or you may phone CareCredit directly to apply for an account by dialing 1-800-365-8295, or you may apply online at www.carecredit.com.

I certify by my signature that I have read and understand the financial policy stated above:

Signature*

Date*

Date

Surgical Policies

Here at MWVH we want nothing but the best for our patients and their owners. To do that, we strive to give them the highest quality of care especially when it comes to surgery. Please take a moment to review our policies for surgery procedures and initial at the bottom of each section:

Scheduling Policy

Upon scheduling for any surgery or teeth cleaning a $25 deposit is required in advance. Your deposit will be applied to the cost of the procedure. For Best Friend's Certificates a deposit is required, however, it will be refunded if no additional expenses are incurred. *Deposits are nonrefundable for no shows

I understand and agree to the scheduling policy (initial)*

Vaccination Policy

To help protect all hospital patients, surgery patients are required to be current on all vaccinations. If not, vaccinations will be given at the time of surgery at an additional cost to the owner.

Canines must be current on Rabies, DHPL-Parvo and Bordetella. Felines must be current on Rabies and FVRCP.

I understand and agree to the vaccination policy (initial)*

Preoperative Bloodwork Policy

Preoperative bloodwork (CBC/Chem) is recommended for all surgery patients but is mandatory for patients 8 years of age or older undergoing general anesthesia. This bloodwork allows our veterinarians to assess the patient's overall health, ensuring that your pet is a good candidate for anesthesia and decreasing certain risks and complications. The preoperative bloodwork is an additional $149.40 and when applicable, will be quoted to you at the time of scheduling.

I understand and agree to the bloodwork policy (initial)*

Pain Management Policy

Post-operative pain medications are required at an additional charge for all pets after surgical procedures (excluding teeth cleanings without extractions). Pain management is important to your pet’s overall healing process; an injection will be given immediately prior to surgery and your pet will be sent home with pain medications for at least 4 days following surgery. Animals may not appear to be in pain after surgery, but they are. Alleviating pain will allow your pet to be more comfortable and heal faster.

Charges for post-op pain medication vary by weight which will be checked the morning of the procedure and will be included in the quote given upon scheduling.

Dogs 1-40lbs $38 41-80lbs $48 81-120lbs $59 >121lbs $75 Cats $32

I understand and accept the pain management policy (initial)*

Prescription Policy

Dispensing and prescribing a prescription product requires a Veterinarian-Client-Patient Relationship (VCPR). This means that veterinarians are required to examine your pet and understand your pet’s health care needs, as well as have a relationship with you before medication can be prescribed. Without a valid VCPR, our use of veterinary prescription drugs or the use of any pharmaceutical in a manner that differs from their labeled use is unethical and is illegal under federal law.

Refills

Please plan ahead and allow 24 hours for your pet’s prescriptions to be refilled. A 24-hour notice is required to give our doctor time to review your pet’s medical record, make sure no changes are needed to the prescription, and approve the refill. In addition, it also gives our staff time to fill the prescription.

For the safety of your pet, certain medications require blood testing and check-ups at specific intervals in order for your pet to continue the medication.

Written Prescriptions

A fee of $7.50 will be charged for preparing prescriptions for medications that we carry at Midwest Veterinary Hospital but are to be filled at another pharmacy. This fee is to help cover the cost of our staff's time to review your pet's medical history, prepare the prescription, and ensure it is valid and medically necessary.

To request a prescription for off-site filling, please do the following:

Inform our staff that you would like a prescription to be prepared for off-site filling.
Our staff will review your pet’s medical records and provide the prescription within 3 business days.
A handwritten prescription will be provided for you to take to the pharmacy of your choice.

Please note:

We recommend checking with your chosen pharmacy before requesting the prescription to ensure they accept handwritten prescriptions or require other forms.
We also recommend that you keep a copy of the prescription for your records.
We will be happy to provide refills for prescriptions filled elsewhere, as needed. However, when the pharmacy requires a newly written prescription, a new fee will be charged.

Online Pharmacies

Prescription requests can be made electronically. The prescription fee of $7.50 will be applied and must be paid prior to the approval of the prescription. Our staff works diligently with a variety of manufacturers to find the best price and quality products and medications for your pet. We cannot vouch for the quality, dosing, proper storage, or legitimacy of medications purchased online. Please speak with our receptionists to learn more about our product prices, rebates and reward programs (available for select prescription products only).

I understand and accept the prescription policy (initial)*

Client Information

Patient Information

Other Pets

ALL FEES ARE DUE AND PAYABLE UPON COMPLETION OF SERVICES

Check out our client portal at https://bit.ly/mwvhclientportal