Breadcrumb Home For Pet Owners Patient Registration If possible, please complete and submit this form online prior to your arrival at CUVS. Contact Information Title - None -Mr.Mrs.Ms.Dr. Owner First Name Owner Last Name Address City State Zip Code Owner Cell Phone Owner Landline Owner Work Phone Owner Email Spouse / Partner First Name Spouse / Partner Last Name Spouse / Partner Cell Phone Spouse / Partner Email Preferred Method(s) of Communication: Owner Cell Owner Landline Owner Work Spouse / Partner Cell Owner Text Owner Email May we communicate with you via text and email? Examples: appointment reminders, medical updates, etc. Questions Yes No Text Message Yes No Email Yes No If we are unable to reach you, who may we contact in case of emergency? Emergency Contact Name Emergency Contact Phone Do you authorize this person to make urgent treatment decisions if you are unreachable? Yes/No? Yes No Please list people in addition to your primary care veterinarian to whom we may release information: Name Phone How did you hear about us? Pet Information Species: Canine Feline Pet Name: Breed: Date of Birth: Pet Color Sex: Male Male/Neutered Female Female/Spayed Primary Veterinarian Name and Phone Number By listing your primary care veterinarian above, you are authorizing our hospital to release patient information to the hospital or veterinarian(s) listed. Are there any other veterinarians to whom you would like us to send updates or information? (If yes, please list here) Presenting Problem / Special Needs / Concerns: Send us a photo of your pet One file only.10 MB limit.Allowed types: gif, jpg, png. In support of CUVS as an academic facility, I understand that CUVS may, with my permission, use records, images, and laboratory submissions to further advance knowledge, and help the wellbeing of other pets. In support of Cornell's Veterinary Biobank, samples of blood are archived for DNA testing in pursuit of new diagnostic tests and treatments. We will save a small volume of blood left over from our usual diagnostic testing, or may collect a small blood sample. Please check below if you DO NOT want any samples from your pet for the Biobank. Please DO NOT collect or archive blood samples from my pet for the Biobank. I hereby authorize CUVS to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I understand that a deposit toward the medical plan is required before diagnostics and treatments can be initiated. I agree to pay for the cost of all services to which I grant verbal or written consent. I understand that payment in full is required prior to discharge of my pet from CUVS. Signature Date Share this:
If possible, please complete and submit this form online prior to your arrival at CUVS. Contact Information Title - None -Mr.Mrs.Ms.Dr. Owner First Name Owner Last Name Address City State Zip Code Owner Cell Phone Owner Landline Owner Work Phone Owner Email Spouse / Partner First Name Spouse / Partner Last Name Spouse / Partner Cell Phone Spouse / Partner Email Preferred Method(s) of Communication: Owner Cell Owner Landline Owner Work Spouse / Partner Cell Owner Text Owner Email May we communicate with you via text and email? Examples: appointment reminders, medical updates, etc. Questions Yes No Text Message Yes No Email Yes No If we are unable to reach you, who may we contact in case of emergency? Emergency Contact Name Emergency Contact Phone Do you authorize this person to make urgent treatment decisions if you are unreachable? Yes/No? Yes No Please list people in addition to your primary care veterinarian to whom we may release information: Name Phone How did you hear about us? Pet Information Species: Canine Feline Pet Name: Breed: Date of Birth: Pet Color Sex: Male Male/Neutered Female Female/Spayed Primary Veterinarian Name and Phone Number By listing your primary care veterinarian above, you are authorizing our hospital to release patient information to the hospital or veterinarian(s) listed. Are there any other veterinarians to whom you would like us to send updates or information? (If yes, please list here) Presenting Problem / Special Needs / Concerns: Send us a photo of your pet One file only.10 MB limit.Allowed types: gif, jpg, png. In support of CUVS as an academic facility, I understand that CUVS may, with my permission, use records, images, and laboratory submissions to further advance knowledge, and help the wellbeing of other pets. In support of Cornell's Veterinary Biobank, samples of blood are archived for DNA testing in pursuit of new diagnostic tests and treatments. We will save a small volume of blood left over from our usual diagnostic testing, or may collect a small blood sample. Please check below if you DO NOT want any samples from your pet for the Biobank. Please DO NOT collect or archive blood samples from my pet for the Biobank. I hereby authorize CUVS to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I understand that a deposit toward the medical plan is required before diagnostics and treatments can be initiated. I agree to pay for the cost of all services to which I grant verbal or written consent. I understand that payment in full is required prior to discharge of my pet from CUVS. Signature Date
