New Client Form - Cornell Center Animal Hospital

Cornell Center Animal Hospital - Beaverton, Oregon

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About
Services
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Contact & Hours
New Client Form
Book Appointment
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CALL (503) 645-1564

Schedule Appointment Online

Pet Stethoscopes - Cornell Center Animal Hospital

New Client Information

We are currently accepting new clients!
To schedule an appointment with us you can:
– Download our iOS or Android app
– Call us at 503-645-1564
– Use the below form to give us your information. We will contact you to schedule an appointment.

Owner's Name*
Co-Owner*
Owner Email
Enter Email Confirm Email
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*
Male or Female*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Color*
Microchip#*
Allergies/Medical Alert?*
Spayed/Neutered?*
What veterinary clinic has this pet previously been seen at?*
PET NO. 2
Name
Species
- Dog
- Cat
Breed
Male or Female
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Color
Microchip#
Allergies/Medical Alert?
Spayed/Neutered?
What veterinary clinic has this pet previously been seen at?*
PET NO. 3
Name
Species
- Dog
- Cat
Breed
Male or Female
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Color
Microchip#
Allergies/Medical Alert?
Spayed/Neutered?
What veterinary clinic has this pet previously been seen at?*
PET NO. 4
Name
Species
- Dog
- Cat
Breed
Male or Female
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Color
Microchip#
Allergies/Medical Alert?
Spayed/Neutered?
What veterinary clinic has this pet previously been seen at?*
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 24 hours 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 then taken to the local animal control. 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. Our Hospital only accepts cash, Visa, MasterCard, Discover, 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
MM slash DD slash YYYY
How Did You Hear About Us?*
Please specify*
Promotion Code*
Phone
This field is for validation purposes and should be left unchanged.

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