New Client Policy Form

New Client Form

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

Email*

I decline to provide my e-mail information

Yes

Reason

Occupation

Secondary Contact

First Last

Secondary Phone

Occupation

Date of Appointment*

Please list all veterinarians that we should share our findings with

Primary Veterinarian*

Primary Veterinarian Clinic*

Specialty Veterinarian

Specialty Veterinarian Clinic

Patient Information

Pet Name*

Species*

Canine
Feline
Other

Other

Breed*

Color*

Sex*

Female
Spayed Female
Male
Neutered Male

Date of birth/approximate age*

History

Reason for visit*

Other conditions your pet is currently being treated for

Current medications

Date of last Heartworm test

Are you giving monthly Heartworm preventative?*

Yes
No

Does your primary veterinarian need anesthetic recommendations?*

Yes
No

Are there any related pets with heart disease?*

Yes
No

Current Pet 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/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.

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.

PRESCRIPTIONS: 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.

FINANCIAL: 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, 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.

CANCELLATION POLICY: We reserve the right to collect a $50 security deposit in instances of multiple and/or short notice cancellations. Appointments must be modified a minimum of 48 hours prior to your appointment start time to avoid forfeiting this deposit.

PHOTOS: 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.

If you have an after-hours emergency here is a list of the emergency clinics in the Portland-metro area. If none of these are convenient for you, please contact your local veterinary office for emergency services in your area.:

Emergency Veterinary Clinic of Tualatin 503-691-7922
DoveLewis Emergency Animal Hospital 503-228-7281
Tanasbourne Veterinary Emergency 503-629-5800
VCA Northwest Veterinary Specialists and Emergency 503-656-3999
Columbia River Veterinary Specialists and Emergency 360-694-3007
VCA Southeast Portland Animal Hospital 503-255-8139

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