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
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?
Patient Information
Pet's Name*
Species*
Breed*
Color*
Age or Date of Birth*
Sex*
Neutered or Spayed*
Other Pets
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:

MonthDayYear
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
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ALL FEES ARE DUE AND PAYABLE UPON COMPLETION OF SERVICES
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*

Clear
Date*

MonthDayYear
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*

Clear
Date*

MonthDayYear
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)*

Clear
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)*

Clear
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)*

Clear
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)*

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

After registering for the portal download the MyPetsWellness app to take the portal on-the-go!
Should be Empty:

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