New Client Policy Form - Cardiology Northwest

Primary Contact Information

Primary Contact*

First Last

Current Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Type of phone*

Home Phone
Cell Phone

Is SMS texting OK to this number?*

Yes
No

Email*

Occupation

Secondary Contact Information

Secondary Contact

First Last

Secondary Phone

Occupation

Date of Appointment*

Referring Veterinarian Information

Please list all referring veterinarians with which we should share our findings.

Primary Veterinarian*

Primary Veterinarian Clinic*

Specialty Veterinarian

Specialty Veterinarian Clinic

Pet Insurance Information

If you have pet insurance, please tell us the name of your provider.

We use Trupanion Express for Trupanion clients, or we keep a signed, undated claim form to submit on your behalf.

Patient Information

Pet Name*

Species*

Canine
Feline

Breed*

Color*

Sex*

Female
Spayed Female
Male
Neutered Male

Date of birth/approximate age*

Patient History Information

Reason for visit*

Other conditions for which your pet is currently being treated

Current medications

Please include dosage information, including strength and directions for administration.

Are there any related pets with heart disease?*

Yes
No
I am not sure

Patient Diet Information

What is the brand of your pet's diet?*

Is your pet's diet grain free?*

Yes
No
Don't Know

What are the main ingredients?*

How long has your pet been on this diet?*

CPR/DNR Release

Please indicate below your wishes in the event that your pet requires life saving measures while in our care.*

YES, I authorize CNW to perform CPR on my pet in the event of cardiac or respiratory arrest. I understand that this can incur additional costs of up to $1000. I understand that despite the best effort of the doctors and staff at this facility even the most successful CPR may not allow my pet to regain normal mental and physical health.
NO, please do not perform CPR in the event of cardiac or respiratory arrest.
I choose not to answer at this time, but I understand that I will be required to decide if my pet is having a medical emergency. [Giving this answer may result in additional costs as CPR will be performed immediately in the event of cardiac or respiratory arrest.]

New Client Policies

Please read the following client policy statements and agree to the terms and conditions below. You may also download the Client Policy Form directly by clicking the button below.

Download the New Client Policy Form

CANCELLATION POLICY
Appointments must be modified a minimum of 48 hours (excluding weekends) prior to your appointment start time. We reserve the right to collect a security deposit, up to the value of an exam fee, in instances of multiple and/or short notice cancellations.

FINANCIAL POLICY
Payment is due in full at the time services are rendered. We do not offer billing or in-house payment plans/financing. We strive to provide estimates for all services before performing them. Sometimes in a hospitalization or emergency event it is difficult to give an accurate estimate. Please tell us if you have specific cost concerns. We accept cash, check, VISA, MasterCard, Discover Card, American Express, and CareCredit.

PRESCRIPTION POLICY
To best serve your pet’s changing needs, we require regular recheck examinations for prescription approvals. Rechecks are recommended per the severity of your pet’s cardiac disease and are generally less expensive than the initial visit. We cannot accept returned prescriptions for a refund once they have left our hospital, but we will gratefully accept them as a donation to use in cases where the owners cannot afford care.

"A Veterinary-Client-Patient Relationship (VCPR) must be in place for a veterinarian to be able to legally provide treatment, prescribe medications, or administer vaccines to an animal. The veterinarian must have examined the animal within the last year in order to establish the VCPR." - Oregon Veterinary Medical Association (OVMA).

I have read and understand the above policies and agree to the terms and conditions stated therein.*

Yes
No (I will read and sign at my appointment)

PHOTO POLICY
Cardiology Northwest may publish photos of me and/or my pet for educational and promotional purposes including the business website, Facebook, Instagram, Twitter, and/or publications.

I decline use of my pet’s photographs for promotional/educational purposes*

Yes
No

Add a picture of your pet!

Once you submit this form you will receive an email from info@heartvet.com confirming its completion. If you do not receive an email, please call our office for confirmation before your scheduled appointment.