Northland Veterinary Services

8560 Topper Road
Iron River, WI 54847

(715)372-5590

northlandvet.net

New Client Check In

If you already have called or would like to call and make an appointment, you can assist us to expedite your check in by submitting this form.
*If you have a new pet, but are already a client of ours, please use the same form below and write "New Pet" in the additional information box.
Thank you for your cooporation in letting us assist you.

New Client

Name (required)
First Name (required)
Last Name (required)
Address: Sorry, NO P.O. Box's please! (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
Driver's License # (required)

SSN#

E-Mail Address (required) :
Did you receive a referral from one of our clients? If yes, whom?

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Color

Sex: (required)
Male
Female


Neutered/Spayed
Neutered
Spayed


Are your pets vaccines current?
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


Reasons or conditions that prompted your visit?

Additional Information/Special Requests

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Northland Veterinary Services and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5%. Any balance that is carried over a period of 60 days will accrue a monthly finance charge of $4.50. Any balance that I leave unpaid will be forwarded to Northland Veterinary Services's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. I am also aware that there is a $30 fee for returned checks.
I have read this statement and -
I Agree
I Disagree



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