If possible, please complete and submit this form online prior to your arrival at CUVS.

Contact Information
Preferred Method(s) of Communication:
Questions Yes No

If we are unable to reach you, who may we contact in case of emergency?
Do you authorize this person to make urgent treatment decisions if you are unreachable?

Please list people in addition to your primary care veterinarian to whom we may release information:
Pet Information

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?

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.

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.

Share this: