New Client Form

Owner(s) Information:
Name of Owner:*
First Last
Name of Partner / Spouse:
First Last
Current Address*
Street Address City State ZIP Code
Owner Phone Number(s)
Primary*
Secondary
Work / Other
Primary Phone Type*
- Cell
- Landline
Secondary Phone Type
- Cell
- Landline
Partner / Spouse Phone Number*
Partner / Spouse Phone Type*
- Cell
- Landline
Owner Email*
Partner / Spouse Email*
How did you hear about us?

Please list all veterinarians that should be informed of your pet’s visit here today.

(add multiple vets by clicking the button next to the input field(s) below.)

Primary or Specialty Veterinarian	Clinic

Patient Information
Pet Name*
Date of Birth*
MM slash DD slash YYYY
Species*
- Dog
- Cat
Sex*
- Male
- Female
Neutered / Spayed*
- Yes
- No
History
Reason for Visit:*
Other Medical conditions your pet is currently being treated for:*

Current medications (please bring to your appointment):

Is your pet currently receiving medications to prevent heartworm/fleas/ticks? Please list all medication(s):

(add more medications by clicking the button next to the input field(s) below.)

Medication	Dosage

What diet is your pet currently being fed?*

The majority of correspondence will be sent by via email, or text to reduce environmental impact.
Cancelled / Missed Appointment Policy:*
We all have times when an unforeseen situation arises and cause the cancellation of an appointment at the last minute. It happens to everyone. However, if an appointment is cancelled more than once within 48 hours of that scheduled appointment, or more than one appointment is missed without notification, the full amount of that appointment will be billed to you. We may also ask that you pay a nonrefundable deposit when rebooking. Clients who are more than 10 minutes late may be asked to reschedule. Please, just be considerate.
I agree to the cancellation policy above.
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.
Check to decline
Financial Information:*
Heart of Oregon Veterinary Cardiology accepts cash, check, debit cards, Visa/MasterCard/American Express/Discover card and Care Credit 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.
I understand and agree.
By signing this statement, I signify that I agree and accept these financial conditions.
Signature*
Date*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

New Client Form

Owner(s) Information:

Owner Phone Number(s)

Patient Information

History

Contact Info