Hueytown Veterinary Clinic
Check-In
Pet Services
Online Store
About Us
Contact
Lodge
News
New Client
New Pet
Check-In
/
Pet Services
/
Online Store
/
About Us
/
Contact
/
Lodge
/
News
/
New Client
/
New Pet
/
New Client Form
Check-In
/
Pet Services
/
Online Store
/
About Us
/
Contact
/
Lodge
/
News
/
New Client
/
New Pet
/
Please fill out and submit this form and a new pet form if you are a new client.
Owner's Name
*
First Name
Last Name
Co-Owner/Second Contact Name
First Name
Last Name
Email
Billing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mailing Address (if different)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Social Security Number
*
Driver's License Number
*
Primary Phone
*
(###)
###
####
Secondary Phone
(###)
###
####
Employer's Name
Work Phone
(###)
###
####
Agreement One
*
Upon admission of my pet(s) to this veterinary facility, I hereby give my permission to the doctors therewith associated to perform any and all indicated and appropriate medical and surgical procedures necessary in their efforts to sustain and support its (their) health.
I Agree
Agreement Two
*
I also give my permission for any elective, medical, surgical, and/or diagnostic procedure(s) requested by me or my agent to be performed. I further agree that the doctors and staff of this clinic shall NOT be held responsible in the event of disability and/or death associated with any of the above procedures.
I Agree
Agreement Three
*
I further agree to pay the normal charges for these medical and surgical services and, as to the charges, therefore waive rights of exemption and agree to pay the cost of collection, including attorney fees.
I Agree
Electronic Signature Agreement
*
By selecting the "I Accept" checkbox, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Hueytown Veterinary Clinic.
I Accept
Thank you!