New Client Information Form

Client Information

* Indicates required field

Name *

First

Last

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Preferred Method of Contact *

Phone Email

Would you like email reminders? *

Yes No

Home Phone *

Mobile Phone *

Work Phone *

Occupation *

Driver's License # *

Driver's License State *

Is your appointment already scheduled? *

Preferred Hospital *

Pet Insurance (If Applicable)

Provider Name *

Policy Number *

How did you hear about Petcardia? *

Primary Care Veterinarian Online Search Facebook Friend

Are you... *

Over the age of 65? Active or Retired Military?

We'd like to thank your friend for the referral! *

First

Last

Referral's Email *

Patient Information

Patient Name *

Age *

Gender *

Species *

Breed *

Primary Care Veterinarian *

Color/Markings *

What brand of food do you feed your pet? *

Is your pet's food grain-free? *

Medications *

Please describe any temperament issues of which we should be aware. *

In the event that your pet goes into cardiac arrest would you prefer we... *

Does your pet have either a microchip or tatoo? *

Microchip Tatoo None

Please list the names of others who have permission to make decisions on behalf of your pet.

Alternate Contact #1 *

First

Last

Contact #1 Phone *

Contact #1 Relationship *

Alternate Contact #2 *

First

Last

Contact #2 Phone *

Contact #2 Relationship *

May we use a photo of your pet and information from the case for marketing (print, facebook, etc). *

Petcardia Policies

Please check the boxes to demonstrate that you have read and agree to the following policies.

Treatment Authorization *

I hereby authorize Petcardia Veterinary Cardiology to perform medical and initial diagnostic/procedures on my pet as required for diagnosis and treatment. I understand that I can terminate treatment at any time.

Medication Request *

Medication requests and pick-ups must be made during Petcardia business hours. Petcardia business hours vary by location. Urgent refill requests outside of Petcardia business hours, may be filled by the emergency department of our partner hospitals. Emergency exam fees may apply.

Payment Agreement: *

Payment is due when services are rendered. For surgery cases, a deposit is required in advance. The balance is due upon discharge from the hospital. Payment may be by cash, personal in state check (with proper identification), Care Credit, or accepted credit cards. To avoid misunderstandings, please let us know immediately if these terms are not satisfactory.

Statement of Understanding
I understand that I, as the owner or agent, am financially responsible to Petcardia Veterinary Cardiology for all charges relating to this patient. I have read and agree to the treatment authorization. I also accept the financial obligations.

I agree

Southern Colorado
5886 Tutt Blvd.
Co. Springs, CO 80923
719-602-7800

South Denver
774 Maleta Ln
Castle Rock, CO 80108
720-724-8013

Denver
10140 West 44th Ave.
Wheat Ridge, CO 80033
720-724-8010

North Denver
2000 W S. Boulder Rd.
Lafayette, CO 80026
720-724-8012

Northern Colorado
227 W. 67th Ct.
Loveland, CO 80538
970-775-8002