New Client Form - Cornell Center Animal Hospital

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About
Services
Resources
Online Store
- Vetsource
- Purina Pro Plan
Contact & Hours
Book Appointment

CALL (503) 645-1564

Veterinary tools

Client Information
Thank you for giving us the opportunity to care for your pet(s). Please help us meet your needs by taking a moment to complete this information.
Owner's Name*
Co-Owner*
Address*
Address Apt# City State Zip
Home Phone
Cell Phone
Work phone
Co-Owner Phone
Do you have currently have Pet Insurance? If so ,who?
PET NO. 1
Name*
Species*
- Dog
- Cat
Breed*
Date*
Date Format: MM slash DD slash YYYY
Color*
Microchip#*
Allergies/Medical Alert?*
Spayed/Neutered?*
PET NO. 2
Name
Species
- Dog
- Cat
Breed
Date
Date Format: MM slash DD slash YYYY
Color
Microchip#
Allergies/Medical Alert?
Spayed/Neutered?
PET NO. 3
Name
Species
- Dog
- Cat
Breed
Date
Date Format: MM slash DD slash YYYY
Color
Microchip#
Allergies/Medical Alert?
Spayed/Neutered?
PET NO. 4
Name
Species
- Dog
- Cat
Breed
Date
Date Format: MM slash DD slash YYYY
Color
Microchip#
Allergies/Medical Alert?
Spayed/Neutered?
Referral
How were you referred to our hospital?
GOOGLE
FACEBOOK
SIGN/LOCATION
COUPON
POSTCARD
OTHER
Is there someone we can think?
WHO?
We would be happy to give you an estimate upon request.
*All Professional fees are due at the time services are rendered.*
Authorization
I, the undersigned, do hereby certify that I am the owner, or assuming responsibility, financial or otherwise, for the animal being presented to Cornell Center Animal Hospital for the treatment of care. I hereby consent and authorize Cornell Center Animal Hospital to receive, prescribe for or treat, as indicated, this animal presented. It is thoroughly understood that I assume all risks. I agree, if appropriate, to pick up this animal at the designated date and time agreed to by myself and Cornell Center Animal Hospital. If in the event that the animal is not picked up, there will be a notice of 10-days to come claim the animal or it will be considered abandoned. The animal will be held in the manner that is considered to be most appropriate for the animal and the hospital. It is understood that I am not released from costs associated with the care of the pet. We do not bill and all fees are due when services are rendered. Deposits are required for all hospitalized patients. Our Hospital only accepts cash, personal checks (driver’s license required), Visa/MasterCard, American Express, Discover Card, Scratchpay, and Care Credit. I understand that if I do not pay my balance in full, that I am responsible for all statement fees, finance charges, and attorney/collection fees.*
Date
Date Format: MM slash DD slash YYYY

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