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
Petcardia Pharmacy
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New Client Information Form
Diet History Form
Client Education
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Review
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Petcardia Feedback
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Veterinary Referral Form
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DCM Clinical Trial
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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?
*
Yes
Please contact me to schedule an appointment
Preferred Hospital
*
Denver - Wheat Ridge Animal Hospital
Loveland - Vet. Specialists of Northern Colorado
Lafayette - Boulder Road Vet. Specialists
Castle Rock - Vet. Specialists of the Rockies
Colorado Springs - Powers Pet Emergency and Speciality
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
*
Dog
Cat
Other
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...
*
Perform CPR
Do Not Resuscitate
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).
*
I give permission
I do not give permission
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
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
Petcardia Pharmacy
Testimonials
Forms
>
New Client Information Form
Diet History Form
Client Education
>
Videos
Heart Conditions
Care Credit
Scratch Pay
Review
>
Petcardia Feedback
For Veterinarians
Veterinary Referral Form
Continuing Education
Careers
Locations
DCM Clinical Trial
More
Love Like Harley
NutritionalDCM