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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.

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 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. By signing below, I acknowledge that I am at least 18 years of age.

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Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

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Timestamp

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May 3, 2021 8:44 am EDT

New Uploaded by Beaver Brook - bbah@beaverbrookah.com IP 72.200.141.178