New Patient Form

I, the undersigned and legal owner or agent for the above-described pet, authorize Cali’s Cottage Veterinary Hospital (CCVH) and its staff to perform any necessary examinations, diagnostics, and treatments. I understand the risks involved and give permission for procedures such as sedation, anesthesia, dentistry, and/or surgery, if deemed necessary. Further, I acknowledge that I have been informed of, and understand, the nature, risks, benefits, and alternatives to the procedures being performed, including the risks associated with anesthesia and surgical intervention.

I understand that an estimate may be given if I request one, and that a deposit may be requested for payment of estimated services. I understand that results cannot be guaranteed, and outcomes may vary. *

I accept full financial responsibility for all charges incurred by the pet and that these charges are due and payable at the time of service by cash or credit card. I understand that unpaid balances may be subject to a monthly service charge of 10% and that collection fees may be added if the balance is referred to a third-party agency. I understand that CCVH does not provide veterinary services during the nighttime hours.

I understand that if I fail to retrieve my pet within 3 days of the agreed discharge date, and if reasonable efforts to contact me are unsuccessful, CCVH may consider the pet abandoned under California Civil Code §1834.5. I understand that abandonment does not relieve me of financial responsibility. *

I understand that prescription medication may be obtained directly from CCVH, or CCVH will provide me with a written prescription that I may have filled by a pharmacy of my choice that holds a valid California pharmacy license. I understand that it is illegal for CCVH to dispense or refill legend prescription medications without prior examination and current knowledge of my pet’s health. CCVH cannot fill prescriptions from other veterinarians without their own prior examination. *

I may be referred to specialists for expert procedures and it is my choice to decline or proceed with my pet's treatment and financial obligation with these specialists that are not affiliated with CCVH. I have the opportunity to request a specialist referral at any time. *

In compliance with California Proposition 65, I acknowledge that chemicals and materials used at CCVH, including X-ray equipment, may expose individuals to substances known to the State of California to cause cancer or reproductive harm.

I understand that if my pet is prescribed a Schedule II, III, or IV controlled substance, CCVH is required by California law to report this prescription to the CURES database maintained by the Department of Justic *

I understand I may request copies of my pet's medical records, and CCVH will provide them within a reasonable time. The first copy may be provided at no charge; additional copies may incur a fee. *

I acknowledge and consent that any verbal communications between myself and the CCVH staff may be recorded for the purpose of accurately documenting medical history, treatment discussions, and patient care. I also consent to the photographing of my pet for medical records, patient identification, and treatment purposes. These recordings and images will be used by CCVH for clinical and administrative use and will not be shared publicly without additional written consent. I understand that these recordings and images are part of the medical record and will be kept confidential in accordance with applicable privacy laws.

If I have any concerns regarding the care provided, I agree to contact CCVH directly so that we may address and resolve the issue professionally. *