Thank you for the opportunity to care for your family member.  So that we may become better acquainted, please complete the following information.

Name of Owner
Name of Spouse/Partner
Address
City
State
Zip
Owner Contact
Primary Phone
Primary Phone Type:
Secondary Phone
Secondary Phone Type:
Work/Other Phone
Work/Other Phone Type:
Spouse/Partner Contact
Primary Phone
Primary Phone Type:
Secondary Phone
Secondary Phone Type:
Work/Other Phone
Work/Other Phone Type:
Owners Email
Spouse/Partner Email
Texting is okay for appointment reminders
How did you hear about us?
Please list all veterinarians that should be informed of your pet’s visit here today.
Primary Veterinarian
Clinic
Specialty Veterinarian
Clinic
Other Veterinarian
Clinic
Patient Information
Pet Name
Date of Birth
Type of Pet
Breed
Color
Sex
Reason for Visit
Please provide a brief clinical history
Current medications (please bring to your appointment):
Is your pet currently receiving medications to prevent heartworm/fleas/ticks? Please list type of medication used
Cancelled/Missed Appointment Policy
We all have times that problems arise and cause the cancellation of an appointment at the last minute. It happens to everyone. But if it happens more than twice or more than one appointment is missed without notification, the full amount of that appointment will be billed to you. Clients who are more than 10 minutes late may be asked to reschedule. Please, just be considerate.
Media Consent
Heart of Oregon Veterinary Cardiology may publish photos of me and/or my pet for educational and promotional purposes including the business website, Facebook, and/or publications.
Financial Information
Heart of Oregon Veterinary Cardiology accepts cash, check, debit cards, Visa and MasterCard for payments. Payment is always due at the time of service. There is no billing permitted for services. If payment is not received at the time of service there is a 10% per month billing fee, and non-payment is sent to collections at 90 days. There is a $30 returned check fee.
By signing this statement, I signify that I agree and accept these financial conditions.
Type Name as Signature
Date

Applications for Care Credit and H3 Wellness Plus Cards are third party credit cards available for application