HomeNew Client Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Please take a moment and complete the New Client Form below prior to your first appointment at Berkshire Humane Society Wellness Clinic. Providing this information will allow us to enter your information into our database. Owner’s Information Name *FirstLastAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Cell *HomeIn addition to the owner above, I would like to add another authorized individual. Spouse, Co-Owner, OtherYesNoThe following adults (age 21 or older) are authorized to make medical and/or financial decisions concerning my pet’s care. Name *RelationshipCell (copy) *Home (copy)Pet’s Information Speicies *DogCatPet's Name *Breed *Sex *MaleFemaleColor *DOB or AgeSpayed/NeuteredNoYesReason for Visit * Home Age or Any Additional Notes or Previous Problems We Should Know About?Add a Second Pet? *YesNoPet's Name *Breed *Sex *MaleFemaleColor *DOB or AgeSpayed/NeuteredNoYesReason for Visit *Any Additional Notes or Previous Problems We Should Know About?We recommend that you call your vet and have them send your pet’s records to us prior to your visit in order to help us best manage your pet’s medical care. A $40 booking fee is required when making an appointment. We’ll apply the fee at checkout to services received on the day of your appointment. I hereby authorize the veterinarian to examine, prescribe for, or treat, the above described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of the visit. We accept cash, credit cards and Care Credit as payment methods. Photo ReleaseI give permission to use my pet’s photo for social media, website or newsletter purposes.I give permission to use my photo and my pet’s photo for social media, website or newsletter purposes.GDPR Agreement *I consent to having this website store my submitted information so they can respond to my inquiry.I UNDERSTAND *PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED.Signature of Owner or Agent * Clear Signature Date *Submit