Owner Information

Owner First Name *

Owner Last Name *

Secondary Owner / Authorized Agent Name

Email *

Primary Phone *

Mobile Phone

Work Phone

Address *

City *

State *

Zip Code *

Employer *

Occupation *

Date of Birth *

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

No

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

No

Patient Information

Pet Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Vaccination Status *

Gender *

Spayed or Neutered? *

Presenting problem, special needs, concerns *

Primary Veterinarian Information

Please fill this section in if we are not your primary care veterinary hospital. By listing your primary care veterinarian, you are authorizing Cumberland Animal Clinic to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

By submitting this form, I hereby authorize Cumberland Animal Clinic 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 agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Cumberland Animal Clinic.

I understand that payment for all services and goods from Cumberland Animal Clinic is due at the time they are received unless prior arrangements have been made. I agree to pay, either with cash, Visa, MasterCard, American Express, or Discover. Should there be an outstanding balance on my account, I understand that I will be charged, and agree to pay, a 1.5% per month (18% APR) finance charge.

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New Patient Form

Option 1

Complete Online

Option 2

Print & Complete

Option 3

Complete on Arrival

New Patient Form

Owner Information

Emergency Contact

Patient Information

Primary Veterinarian Information

New Patients Welcome