HMO Agreement

You may submit your HMO application online, HOWEVER, your HMO Agreement will not be valid until your pet has been examined. You will be required to SIGN your HMO Agreement at the time of payment.

* Pet Owner's First Name

* Pet Owner's Last Name

* Date

* Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

* Email Address

* Pet's Name

* Type of Pet

Canine

Feline

Breed

Pet's Age

Date of Birth

* Sex

Male

Female

Pre-existing Conditions: PLEASE EXPLAIN IN FULL

PLEASE CHOOSE THE HMO PLAN YOU WOULD LIKE TO PURCHASE

* TYPE OF HMO PLAN

Adult HMO Plan (1-8 years old) $239.00

Puppy/Kitten HMO Plan (2-12 months old) $294.00

Senior HMO Plan (9 years and older) $294.00

This HMO agreement applies only to the above-mentioned pet. It is not transferable to another animal. It may, however, be transferred to a new owner of the same pet.

Payment for the HMO is due in full at the time of signing of the contract. Discounts will apply for one full year from the time of signing of the contract. There are no refunds once the HMO is in force. There are no pro rated refunds for early termination of the contract.

Preexisting conditions are defined as any congenital or acquired problems that are noted at the time of signing of the contract. If the pet is not examined at the time of the signing of the contract, preexisting conditions will be determined at the first examination after the signing (whether it is the same day or months later).

PLEASE NOTE: If the first examination is for an illness, it will be considered preexisting!

Preexisting conditions are not eligible for discounts under the HMO Agreement. Once a condition has been treated, and there are no recurrences for six months, the condition will no longer be considered preexisting.

The HMO Agreement applies to all work that is performed at County Line Veterinary Hospital and Heritage Veterinary Hospital. Services are discounted by 50%, while tests and products are discounted by 25%. Cases that need to be seen by specialists, or need to be seen at any other facility will not receive discounts for those services. This includes, but is not limited to, referrals for cardiology, ultrasound, ophthalmology, surgery, dermatology, internal medicine, etc. The doctors generally see emergencies, but there are times that cases may need to be referred to an emergency clinic. These (referred) cases will not receive discounts.

Boarding, grooming services, cremation, and food purchases are not eligible for discounts under the HMO Agreement.

HMO Agreements that are being renewed, and have not expired, will not require examination of the pet. No new preexisting conditions will apply to these animals. If the HMO has expired, then problems such as the development of a heart murmur, kidney disease, arthritis, etc. may now be considered as preexisting at the next sign up for an HMO Agreement. If the policy has expired within 30 days, it will be backdated to provide continual coverage and no new pre-existing conditions will apply; after 30 days, an examination will be required at sign up for the HMO. Please note, the HMO renewal is the responsibility of the pet owner and will not automatically be billed to a credit card, etc.

BY CLICKING ON THE "SUBMIT" BUTTON BELOW, I AGREE THAT

I HAVE READ AND ACCEPT THE TERMS OF THIS AGREEMENT AS STATED ABOVE:

To the best of my knowledge, the above information is true and correct. If for any reason this information is found to be false, or if the terms of the contract are not met, the contract will become null and void.

* Indicates Response Required