Beaver Brook Animal Hospital

Client Information Form


Primary Owner’s Name:

Home Number:    

Cell number:     Email:  

Address:     City:      State:      Zip:  

      
      

      

Pet #1

         
                  

Pet #2

           
             

Pet #3

             
                        

By completing the below fields, you give the following members the ability to make financial and/or medical decisions for the pets on this account:

 


   

 
 

 
   

Texting Release

Internet Social Media Photo Release:

I grant Beaver Brook Animal Hospital, its representatives and employees the right to share photographs of  my pet and/or me in a social media setting including but not limited to Facebook, our Website, and/or our Blog.

By checking this box you give permission for BEAVER BROOK ANIMAL HOSPITAL to send your pets records upon request made by 3rd parties, ie insurance, referral hospitals, emergency, other clinics/hospitals. You acknowledge that the records will be sent without further contact to you.

Please Sign the Following Authorization for Treatment:

I hereby authorize the staff of Beaver Brook Animal Hospital to render any treatment that is deemed necessary to my pet(s) health while in custody of the hospital. I understand non-refundable deposits for certain appointments may be required.  I understand that to receive services my pet will need to be examined by a Veterinarian. I understand that in the event of any unusual or emergency circumstances, the staff will make every attempt to contact me or my designated representative before, if time permits, proceeding with 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 professional fees are to be paid at the time services are rendered and a deposit is required on all pets admitted to the hospital. I understand that respect and courtesy are required and negative public comments may results in termination of the Veterinary client patient relationship.  By signing below, I acknowledge that I am at least 18 years of age.

Leave this empty:

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Signature Certificate
Document name: Client Information Form
lock iconUnique Document ID: 3280f8df3ea8af64dbc8b195e14b081b1a87f7c4
Timestamp Audit
January 11, 2020 8:05 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Howard Asher - howard.asher@beaverbrookah.com as a CC'd Recipient Ip: 24.147.89.21
January 11, 2020 8:13 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Howard Asher - howard.asher@beaverbrookah.com as a CC'd Recipient Ip: 24.147.89.21
January 11, 2020 8:19 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Howard Asher - howard.asher@beaverbrookah.com as a CC'd Recipient Ip: 24.147.89.21
January 12, 2020 12:48 am ESTClient Information Form Uploaded by Beaver Brook - bbah@beaverbrookah.com IP 98.175.158.97
January 12, 2020 12:52 am ESTBeaver Brook - bbah@beaverbrookah.com added by Howard Asher - howard.asher@beaverbrookah.com as a CC'd Recipient Ip: 24.147.89.21
January 12, 2020 9:22 am ESTBeaver Brook - bbah@beaverbrookah.com added by Howard Asher - howard.asher@beaverbrookah.com as a CC'd Recipient Ip: 24.147.89.21
January 12, 2020 9:43 am ESTBeaver Brook - bbah@beaverbrookah.com added by Howard Asher - howard.asher@beaverbrookah.com as a CC'd Recipient Ip: 24.147.89.21
January 12, 2020 10:06 am ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 24.147.89.21
January 25, 2020 7:46 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 24.147.89.21
January 30, 2020 5:11 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 63.241.189.4
February 1, 2020 10:35 am ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 174.242.135.51
February 17, 2020 4:23 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.215.52.140
February 25, 2020 3:11 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.215.52.140
February 27, 2020 10:06 am ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.215.52.140
March 4, 2020 6:30 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 24.147.89.21
April 17, 2020 6:20 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.215.52.140
May 6, 2020 9:15 am ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.215.52.140
May 6, 2020 10:09 am ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.215.52.140
July 24, 2020 12:26 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.215.52.140
August 18, 2020 12:39 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 70.168.6.118
September 9, 2020 5:26 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 70.168.6.118
September 18, 2020 2:17 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 70.168.6.118
March 31, 2021 11:24 am ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 103.138.147.222
April 5, 2021 2:51 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
April 26, 2021 8:27 am ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
April 26, 2021 8:29 am ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
April 30, 2021 4:51 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 70.168.6.118
April 30, 2021 4:56 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 70.168.6.118
May 3, 2021 8:25 am ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
May 3, 2021 8:40 am ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
May 3, 2021 10:17 am ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
May 5, 2021 8:54 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
May 5, 2021 8:55 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
May 5, 2021 8:57 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
May 5, 2021 9:12 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
May 5, 2021 9:26 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
May 5, 2021 9:33 pm ESTBeaver BBAH - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
May 5, 2021 10:00 pm ESTHoward Asher - hasher13@yahoo.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
May 5, 2021 10:35 pm ESTBeaver Brook - bbah@beaverbrookah.com added by Beaver Brook - bbah@beaverbrookah.com as a CC'd Recipient Ip: 72.200.141.178
Audit trial Qr code
This audit trail report provides a detailed record of the online activity and events recorded for this document.
https://beaverbrookah.com/
Audit Trail Serial# 89322576e24cf5ecabb1aca131c2d51e