New Client Information Form

Petcardia
- The Petcardia Team >
  - Our Doctors >
    
    Dr. Amy Dixon-Jimenez
    
    Dr. Allison Heaney
    
    Dr. Kendra LaFauci
    
    Dr. Samantha Salmon
    
    Dr. Marta Karn
  - Our Cardiology Technicians >
    
    Beth
    
    Bryce
    
    Chelsea
    
    Jackie
    
    Jessica
    
    Jocelyn
    
    Karinna
    
    Lexus
    
    Morgan
    
    Nicole
    
    Patti
    
    Rachel
For Clients
For Veterinarians
Locations
DCM Clinical Trial
More
- Love Like Harley
- NutritionalDCM

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 *

Pet Insurance Provider (If Any)

Policy Number *

Pet Insurance Policy Number (If Any)

How did you hear about Petcardia? *

Primary Care Veterinarian Online Search Facebook Friend

check all that apply

Are you... *

Over the age of 65? Active or Retired Military?

please check all that apply

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 list all current medications, including supplements.

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.

Please check the box to demonstrate that you agree to these terms.

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.

Please check the box to demonstrate that you agree to these terms.

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.

Please check the box to demonstrate that you agree to these terms

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