New Client FormPrimary Contact* First Last Current Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Primary Phone*Type of phone* Home Phone Cell Phone Email* I decline to provide my e-mail information Yes ReasonOccupationSecondary Contact First Last Secondary PhoneOccupationDate of Appointment*Please list all veterinarians that we should share our findings withPrimary Veterinarian*Primary Veterinarian Clinic*Specialty VeterinarianSpecialty Veterinarian ClinicPatient InformationPet Name*Species*CanineFelineOtherOtherBreed*Color*Sex*FemaleSpayed FemaleMaleNeutered MaleDate of birth/approximate age*HistoryReason for visit*Other conditions your pet is currently being treated forCurrent medicationsDate of last Heartworm testAre you giving monthly Heartworm preventative?*YesNoDoes your primary veterinarian need anesthetic recommendations?*YesNoAre there any related pets with heart disease?*YesNo Current Pet Diet InformationWhat is the brand of your pet's diet?*Is your pet's diet grain free?*YesNoDon't KnowWhat are the main ingredients?*How long has your pet been on this diet?* CPR/DNR ReleasePlease indicate below your wishes in the event that your pet requires life saving measures while in our care.* YES, I authorize CNW/ACGLO 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 resuscitate my pet in the event of cardiac or respiratory arrest. I chose not answer at this time, but understand that I will be required to make a decision regarding CPR if my pet is having a medical emergency. New Client Policy Form CLIENT POLICY FORM Your first visit to Cardiology Northwest includes the following benefits: Initial exam and consultation for: Establishment of medical history and doctor examination Review of records and previous diagnostic testing Recommendations for additional diagnostic tests Estimate of cost for recommended diagnostic testing Interpretation of all diagnostic tests performed Treatment and medication recommendations to include approval for refills until your pet’s next recheck appointment Follow-up care and recheck recommendations An exam summary, with interpretation of diagnostics and cardiac recommendations, will be sent to your primary veterinarian and any specialists that you request be informed. A phone consultation with your pet’s doctor(s) will be provided if needed. To support our collaborative mission at Animal Care Group of Lake Oswego (ACGLO), we uphold a firm referral policy. Clients referred to Cardiology Northwest, Animal Care Surgical Specialists, Oswego Animal Physiotherapy and Rehabilitation and Lake Oswego Veterinary Emergency, by a veterinarian, will not be able to use The Parkway Veterinary Hospital for general veterinary care. Because we respect the relationship you have with your veterinarian, we ask that you return to them for routine veterinary care. All parties at The Animal Care Group of Lake Oswego have agreed to follow this policy. In order to best serve your pet’s changing needs, we require regular recheck examinations for prescription approvals. Rechecks are recommended according to the severity of your pet’s cardiac disease. Recheck examinations are generally less expensive than the initial visit. 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. We strive to provide estimates for all services before performing them. Sometimes in a hospitalization or emergency situation it is difficult to give an accurate estimate. Please tell us if you have specific cost concerns. We accept cash, check, VISA, Master Card, Discover Card, American Express, and Care Credit. Payment is due in full at the time services are rendered. We do not offer billing or in-house payment plans/financing. We reserve the right to collect a $50 security deposit in instances of multiple or short notice cancellations. Appointments must be modified a minimum of 48 hours prior to your appointment start time to avoid forfeiting this deposit. 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. Check to decline. If you have an emergency, please call us at 503-246-9689, or your primary veterinarian. If it is an after-hours emergency here is a list of the emergency clinics in the Portland-metro area: Lake Oswego Veterinary Emergency (LOVE) 503-850-6296 DoveLewis Emergency Animal Hospital 503-228-7281 Emergency Veterinary Clinic of Tualatin 503-691-7922 VCA Northwest Veterinary Specialists and Emergency 503-656-3999 VCA Southeast Portland Animal Hospital 503-255-8139 Tanasbourne Veterinary Emergency 503-629-5800 Columbia River Veterinary Specialists and Emergency 360-694-3007 If none of these are convenient for you please contact your local veterinary office for emergency services in your area. I have read and understand the above policies and agree to the terms and conditions stated therein. Download the New Client Policy Form 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) 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 email@example.com confirming its completion. If you do not receive an email, please call our office for confirmation before your scheduled appointment.