Just Cats & Little Dogs too

                                             Veterinary Clinic
                                                                          8190 Gadsden Hwy
                                                                                       Trussville, AL  35173

                                                                                    Mary Jane Cionni, DVM

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Some of the forms that have been submitted recently have been unreadable due to encryption issues. Our web master has been contacted and is working on this problem. We do care about you and your kitty, so if you submit a form, and haven't heard from us in 24-48 hrs, please call us at 205-661-2287. Thank you!

Form - New Client

Client Information (required)
First Name (required)
Last Name (required)
Spouse/Other

E-Mail Address :
Address (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)
Employer's Name :
Pet Health History
Pet's Name

Age: Years, Months

Color: (required)

Breed:

Sex: (required)
Male
Female

Hair Coat
Short
Medium
Long

Current Brand of Food

Primary Living Conditions
Indoors
Outdoors
Both
Neutered/Spayed
Neutered
Spayed

Medical records at another veterinary hospital?
Yes
No

Name of Former Veterinary Practice

May we contact your previous veterinary clinic if we have any questions?
Yes
No

Please call me to schedule an appointment.
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

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 Just Cats Veterinary Clinic 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% or 18% per annum. Any balance that I leave unpaid will be forwarded to a collection agency, and will incur a $30 collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree


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