Annual Client Registration Form

Save time during your upcoming appointment! Before your appointment, fill out the necessary documents online at any time from any device.

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Annual Client Registration Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Client ID

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Telephone Numbers(Required)

Email(Required)

Co-owner:

Other individuals authorized to make medical decisions on my behalf:

I authorize photos of my pet(s) to be included on the Cumberland Animal Clinic's website, Facebook page and/or informational materials.(Required)

Yes

No

I hereby authorize the veterinarians to examine, prescribe for, or treat my pet(s). I assume responsibility for all charges incurred in the care of this (these) animal(s). I also understand that charges will be paid at the time services are rendered and that a deposit may be required for surgical treatment.(Required)

I have read and understand.

I am aware that my account is subject to a $40 charge for any appointments missed or cancelled with less than 24-hour notice. To be respectful of the medical needs of other patients, I will call promptly if I am unable to show up for an appointment at the schedule time.(Required)

I have read and understand.

Signature(Required)

Annual Client Registration Form

Annual Client Registration Form

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