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.

Cardiology Northwest New Client Form

Please complete our new client form after you have a confirmed scheduled appointment*, prior to your appointment. You may complete this form via the web form below – or – by downloading the PDF and emailing it to us directly.

*If you do not yet have a scheduled appointment, please contact us to request a visit. This form is not an appointment request form.

Primary Contact Information
Primary Contact*
First Last
Do you already have a scheduled visit?*
- Yes
- No
Appointment Date*
MM slash DD slash YYYY
Current Address
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Type of phone
- Landline
- Cell Phone
Is SMS texting OK to this number?
- Yes
- No
Email
Occupation
Secondary Contact Information
Secondary Contact
First Last
Secondary Phone
Occupation
Referring Veterinarian Information
Please list all referring veterinarians with which we should share our findings.
Primary Veterinarian Clinic
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
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

For patients with suspected or diagnosed heart disease, it’s appropriate to decide in advance whether aggressive measures of resuscitation (CPR) will be performed if needed. In the event of cardiac or respiratory arrest, we will always default to performing CPR unless otherwise noted. This may include chest compressions, administration of emergency drugs, intubation (placing an endotracheal tube into the trachea to administer oxygen), or other emergency measures.
CPR/DNR Consent*
I understand that performing CPR will likely incur additional costs (estimated $300-1000). I also understand that even the most successful CPR rarely restores a pet’s normal mental and physical health.
If you DO NOT wish us to attempt to resuscitate your pet in the event of cardiac or respiratory arrest, please initial below:
DO NOT RESUSCITATE
I do not authorize Cardiology Northwest to perform/facilitate CPR in the event of my pet’s cardiac or respiratory arrest.
New Client Policies
Please read the following client policy statements and agree to the terms and conditions below.
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 (our legal requirements are noted below). 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 permit the use of my pet’s photographs for promotional/educational purposes
- Yes
- No
Add a picture of your pet!
Max. file size: 128 MB.
Once you submit this form you will receive an email from [email protected] confirming its completion. If you do not receive an email, please call our office for confirmation before your scheduled appointment.
If you are unable to submit this form, be sure to go back and ensure that you have completed all the required fields (those with the red asterisk). You will not be able to submit the form if there are missing fields.

How to submit your new client form by Email:

Open the fillable PDF version of the new client form by clicking the button below.
Download the blank form to your computer. DO NOT fill the form out in your browser. The data will not save.
Complete the fillable PDF form using your computer’s PDF reader program.
Save the completed form as a new file and email it to the hospital as an attachment.

If you have any questions or issues with the form, please call us at 503-246-9689.

Download New Client Form

Cardiology Northwest New Client Form

Primary Contact Information

Secondary Contact Information

Referring Veterinarian Information

Pet Insurance Information

Patient Information

Patient History Information

Patient Diet Information

CPR/DNR Release

New Client Policies

CANCELLATION POLICY

FINANCIAL POLICY

PRESCRIPTION POLICY

PHOTO POLICY

How to submit your new client form by Email: