Berkeley Dog & Cat Hospital

Berkeley Dog & Cat Hospital

New Client - Welcome Form
New Client Registration

Let us know a little more about you and your family!
Owner's Name:*

PrefixFirst NameMiddle NameLast Name
Pronouns:*

She/HerHe/HimThey/ThemOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cellular Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Other Phone Number

Area CodePhone Number
Preferred Method of Contact*
Owner's Date of birth:*

DayMonthYear
The Controlled Substance Utilization Review and Evaluation System (CURES) was certified for statewide use by the Department of Justice (DOJ) on April 2, 2018. It requires that a date of birth be kept on file for Adults 18 and over in the event that a controlled substance is prescribed. Visit www.mbc.ca.gov/CURES for detailed information regarding CURES 2.0
Drivers License or ID Number*
Co-Guardian or other authorized agent's name:

PrefixFirst NameMiddle NameLast Name
Co-Guardian's relationship to you (primary owner)
Co-Guardian's cell phone number:

Area CodePhone Number
Co-Guardian's home phone number:

Area CodePhone Number
How did you hear about us?

Internet (NET008)Our Website (NET009)Yelp (NET007)Clinic Sign (SIGN)Friend - Please write name in "other" field belowCurrent Client - Please write name in "other" field belowOther
If you were referred to us by your primary care veterinarian, we will be managing only the condition for which your pet was referred. Please check this box if you would like us to send any test results to them for future reference.*

Yes, please send records to my primary care veterinarianNo, do not send records to my primary care veterinarianI do not have a primary care veterinarian
Please provide your primary care veterinarians name and contact information:
Would you like us to send the report of your pet's visit today to your regular veterinarian?

YesNo
Current Pet Insurance Provider
Upload Blank Insurance Form

Browse Files

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Patient Information
Pet's Name*
Pet's Age/Date of Birth*
Type of Pet*

CanineFelineRodentReptileAvianOther
What Breed and Color is your Pet?*
Pet's sex:*

MaleFemaleNeutered MaleSpayed Female
Previous Veterinarian's Name, Address and Phone
Initial Presenting Problem/ Special Needs/ Concerns:
Do you have an additional pet you are presenting for services today?*

YesNo
Pet's Name
Pet's Age/Date of Birth
Type of Pet

CanineFelineRodentReptileAvianOther
What Breed and Color is your Pet?
Pet's sex:

MaleFemaleNeutered MaleSpayed Female
Previous Veterinarian's Name, Address and Phone
Initial Presenting Problem/ Special Needs/ Concerns:
At Berkeley Dog & Cat Hospital, we deeply cherish our furry patients, and occasionally, we'd love to capture and share their adorable moments on our social media platforms, website, print materials, or other advertising channels. To ensure we respect your preferences, we kindly ask for your permission. Please click on your choice below.*

Yes, Berkeley Dog & Cat Hospital may take and publish photos of my pet.No, Berkeley Dog & Cat Hospital may not take and publish photos of my pet.
Treatment Consent

I, the undersigned owner or agent of the owner, hereby authorize the veterinarian and support staff of Berkeley Dog & Cat Hospital to render any treatment that is deemed necessary to my pet(s) health while in custody of the hospital. I agree that after consultation with me, the hospital's Doctors may prescribe medication for, treat, hospitalize, anesthetize and or perform surgery on my pet. I understand that no guarantee can be made as to the outcome of treatment and that I am encouraged to discuss any concerns I have about the risks of treatment with the attending Veterinarian before any procedures or treatment is initiated.

I, as the owner or acting on behalf of the owner, assume responsibility for all the charges incurred in the care of this animal, including the estimate of charges provided to me in person or over the telephone. I understand that a treatment plan including an estimate of the costs for Veterinary Services will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered and during my pet's ongoing medical treatment.

I hereby authorize the name(s) above to make financial and medical decisions for the patient listed. I understand the 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 I (the owner or agent) am financially responsible to Berkeley Dog & Cat Hospital for all charges relating to this patient. All accounts left unpaid after 30 days will accrue a 1.6% monthly finance charge. Past due accounts are subject to costs of collection and legal fees. I have read and agree to the treatment authorization. I have also read and accept the financial obligations.
I HAVE READ AND UNDERSTAND THIS AUTHORIZATION AND CONSENT FORM*

Yes, I give Berkeley Dog & Cat Hospital consent to treat my petNo, I do not give Berkeley Dog & Cat Hospital consent to treat my pet
Owner's or Agent's Signature:*
Should be Empty:

New Client Registration

Patient Information