OWNER INFORMATION

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone*

Home Phone

Work Phone

Email*

Driver's license #*

Date of birth*

Exp. date*

Occupation*

Employer*

Referred by*

PARTNER/CO-OWNER’S NAME

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone

Home Phone

Work Phone

Email

Driver's license #

Date of birth

Exp. date

Occupation

Employer

Referred by

Consent*

I agree to the below

I hereby authorize Benicia Cat Clinic to examine, prescribe for and treat my pet(s). I agree to pay fees for services rendered at the time my pet is discharged from the hospital or when services are otherwise conducted.
I understand that veterinary service/care is provided after hours as necessary in the judgement of the veterinarian in charge, however, the continuous presence of qualified personnel is not provided.
I also understand that all medical records at this clinic, including radiographs, pertaining to my pet(s) belong to and are property of Benicia Cat Clinic. (Copies are available upon request).

We accept: cash, Mastercard, Visa, Discover, American Express, Care Credit. We DO NOT accept checks.

Patient name*

Is your pet*

Male
Female

Is your pet spayed?

Yes
No

Is your pet neutered?

Yes
No

Age*

Date of birth*

Breed*

Color*

Vaccines current?*

Yes
No

If yes, we require written proof from previous veterinarian or vaccine clinic. Ideally this information is provided before the appointment and is easiest to obtain if we contact your prior veterinarian.

Please provide the name and phone number of the previous clinic:

Microchipped?*

Yes
No

Is your microchipped registered, if yes where

Allergies?*

Yes
No

Does your pet require sedation for veterinary visits*

Yes
No

If your pet requires sedation what type?

Reason for exam*

If your pet has chronic health issues, it is best for us to receive the records several business days to a week before the exam for us to be able to review the case. Please e-mail records to bcatclinic@gmail.com or we can contact your prior veterinarian.

Please provide the name and phone number of the previous clinic*

Add one more pet*

Yes
No

Patient name*

Is your pet*

Male
Female

Is your pet spayed?

Yes
No

Is your pet neutered?

Yes
No

Age*

Date of birth*

Breed*

Color*

Vaccines current?*

Yes
No

If yes, we require written proof from previous veterinarian or vaccine clinic. Ideally this information is provided before the appointment and is easiest to obtain if we contact your prior veterinarian.

Please provide the name and phone number of the previous clinic:

Microchipped?*

Yes
No

Is your microchipped registered, if yes where

Allergies?*

Yes
No

Does your pet require sedation for veterinary visits*

Yes
No

If your pet requires sedation what type?

If your pet has chronic health issues, it is best for us to receive the records several business days to a week before the exam for us to be able to review the case. Please e-mail records to bcatclinic@gmail.com or we can contact your prior veterinarian.

Reason for exam*

Please provide the name and phone number of the previous clinic*

THE FINANCIAL POLICY OF BENICIA CAT CLINIC

Thank you for choosing Benicia Cat Clinic. Our primary mission is to deliver the best and most compassionate veterinary care available to your pet. Furthermore, we are committed to making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Benicia Cat Clinic requires payment in full at the end of your pet’s visit and/or time of discharge.

Our financial policy is as follows:

FULL PAYMENT IS DUE AT TIME OF SERVICE

We accept Cash, Visa, Mastercard, Discover, American Express and Care Credit. We DO NOT accept checks.

If you have Pet Insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance company, but in no way are we responsible for your agreement with the insurance company. We must be paid directly by you and your insurance company will reimburse you per their plans.

For some treatments or hospitalized care, a deposit may be required. Treatment Plans requiring comprehensive care of more than $500.00 will require a 50% deposit to begin your pet’s treatment. Estimates will be given based on our professional opinion. It is possible the final bill could be lower or higher than the estimate. Regardless, you will be responsible for the final fees for services rendered in the best interest of your pet.

YOUR OBLIGATION

All customers are responsible for full payment at the time of services. You are responsible for payments regardless even if a bill is not complete at the time of your visit.

NEW CLIENT DEPOSIT

A new client deposit of $25.00/pet is required to secure an appointment. It will be credited to your first visit. If you and your pet(s) are a" No Show” for the appointment and it is not cancelled 48 business hours prior, we will not refund this deposit.

CANCELLATION/NO SHOW FEE

If you do not show for your appointment and are not a new client and have not cancelled 24 business hours prior to the appointment, we will need to have the appointment fee pre-paid prior to rescheduling.

CLIENT RESPONSIBILITY and ADDITIONAL TERMS

Accounts unpaid after 45 days from day of service are subject to a delinquent fee of $35.00. Furthermore, the unpaid balance is subject to a 1.5% monthly (18% annually) finance charge. If we must submit your unpaid account to a collection process, you will be responsible for all charges our practice incurs; including late fees, finance fees, collection cost, staff costs, court filing fees and reasonable attorney’s fees. Any returned Credit Card payments will carry a $35.00 service charge.

Thank you for understating our Financial Policy. Please let us know if you have questions or concerns.

I have read the Financial Policy. I understand and agree to the terms of Benicia Cat Clinic.

Consent*

I agree to the financial policy

VACCINATION RECORD

Here at Benicia Cat Clinic, careful consideration is given to tailor our vaccination recommendations to meet your cat’s specific health care needs and to avoid over or under vaccinating. Please be advised however, that vaccines do carry some risk in the species, including a possible sarcoma formation at the vaccination site. The risk is minimal, but none the less of a potential fatal consequence. Our Doctor(s) is available to discuss any concerns that you may have.

Consent*

I agree to the vaccination policy

Has your pet(s) ever bitten, scratched or injured any veterinary care providers at previous Veterinary Visits?*

Yes
No

Has your pet(s) ever needed sedation prior to care at their Veterinary Visit?*

Yes
No

If you know the medication, please provide that information

It is our policy to protect the safety of our staff and to provide low stress Veterinary Visits for your pet(s)and to do this your pet(s) may need sedation prior to or at Veterinary Visits.

If sedation is recommended by our staff, we expect you to fully comply with this recommendation and if you are unable or unwilling to do this, we will not be able to provide services.

We appreciate your cooperation.

Dr. Rau and staff at Benicia Cat Clinic

Consent*

I agree to the pet behavior policy

OWNER INFORMATION

PARTNER/CO-OWNER’S NAME

We accept: cash, Mastercard, Visa, Discover, American Express, Care Credit. We DO NOT accept checks.

THE FINANCIAL POLICY OF BENICIA CAT CLINIC

FULL PAYMENT IS DUE AT TIME OF SERVICE

YOUR OBLIGATION

NEW CLIENT DEPOSIT

CANCELLATION/NO SHOW FEE

CLIENT RESPONSIBILITY and ADDITIONAL TERMS

VACCINATION RECORD

Location:

Hours: