Cardio Client Form

New Client & Pet Registration Form Cardiology

Thank you for giving Animal Vision Center the opportunity for care for your pet. Please complete the following information:

"*" indicates required fields

Primary Owner*

First Last

Secondary Owner

First Last

Relationship to Primary Owner?

Phone (primary)*

Phone (secondary)

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Email (primary)*

Email Address (secondary)

Who is your current primary care veterinarian?*

List the names of veterinary hospitals or clinics your pet has visited in the past year(If Any). Please include approximate dates.*

Pet's Name*

Breed*

Species*

Canine

Feline

Avian

Other

Pet's Date of Birth*

MM slash DD slash YYYY

Sex*

Female Intact

Female Spayed

Male Intact

Male Neutered

Reason for Cardiology appointment:*

(ie. heart murmur, collapse, heart failure, etc.)

Past Cardiology Visits (echocardiograms with Dr. MacLean or others):*

Yes

Other

Has you pet has x-rays/radiographs in the last 3-4 months? (yes/no)*

If yes, when and where were these performed.

List All Medication(s)*

Please note medication names, frequency of administration, and dosage. Thank you.

Is your pet exhibiting cough? (yes/no)*

If yes, when and how often does the cough occur (while laying down, drinking water, after exercise, or randomly). How long has your pet had a cough?

Is your pet on medication for a cough? (yes/no)*

If yes, has the medication helped the cough?(stopped/improved/didn't help). Please list which medication, dosage, and frequency.

Is your pet having difficulty breathing? (yes/no)*

If yes, please describe when the difficulty breathing occurs, how long have you noticed difficulty breathing, and what medication have been started to alleviate the difficulty breathing. If medications help, please list which medication, dosage, and frequency.

Is your pet breathing faster than normal? (yes/no)*

If yes, please describe when the abnormal breathing occurs, how long have you noticed abnormal breathing, and what medication have been started to alleviate the abnormal breathing. If medications help, please list which medication, dosage, and frequency.

Is your pet breathing with more effort than normal? (yes/no)*

If yes, please describe when the increased effort occurs, how long have you noticed increased effort, and what medication have been started to alleviate the increased effort. If medications help, please list which medication, dosage, and frequency.

Has you pet had any ER visits for difficulty breathing? (yes/no)*

If yes, please list when and where your pet was treated.

Is your pet exhibiting episode of fainting/collapse? (yes/no)*

If yes, please describe when the collapse episodes occurs, how often, and what occurs immediately prior to collapse. What does a collapse episode entail/look like?

Is your pet exhibiting exercise intolerance? (yes/no)*

If yes, for how long has your pet had exercise intolerance?

Appetite: Does your pet have an increased/decreased/or normal appetite?*

If abnormal, please describe.

Urination: Does your pet have increased/decreased/or normal amount of urination?*

If abnormal, please describe.

Is your pet having diarrhea?*

Yes

Is your pet vomiting?*

Yes

Has you pet recently traveled outside of Washington state? (yes/no)*

If yes, when and where was the travel?

Has your pet been diagnosed with high blood pressure? (yes/no/unknown)*

If yes, when was it diagnosed, is it currently controlled, and for how long has it been controlled?

Has your pet been diagnosed as hyperthyroid? (yes/no/unknown)*

If yes, when was it diagnosed, is it currently controlled, and for how long has it been controlled?

Current Diet*

Please describe including brand, product, amount given and frequency. Thank you.

Is your pet's diet grain free?*

Yes

Known Drug Allergies

Known Food Allergies/Sensitivities

Can they have treats during their visit?

Other Health Conditions/Medications*

Does your pet require a muzzle for veterinary visits?*

Yes

Maybe

Not that I am aware of; this would be the first time a veterinarian would have to muzzle my pet

Does your pet display any of the following types of aggression?*

Fear Aggression

Territorial Aggression

Predatory Aggression

Intra-Household Aggression

Control Aggression

Resource Guarding/Possession Aggression

Leash Aggression

Other/None of the Above

Client Conduct Policy*

By clicking here you have read and agree to Animal Vision Center's client conduct policy

As a client of the Animal Vision Center, you are responsible for complying with our Client Code of Conduct

Client Code of Conduct

The Animal Vision Center seeks to continually provide a welcoming and safe environment for all of our clients and patients. As such, there are behaviors which will not be tolerated:

• Verbal abuse, malicious or harmful statements about others, or profanity
• Any form of harassment
• Making threats or using intimidating tactics
• Allowing your pet to threaten or intimidate another person(s) or patient(s)
• Public disclosure of another’s private information
• Suspicion of being under the influence of alcohol or behavior altering drugs
• Failure to comply with requests by our staff, including leashing/restraining your pet, wearing a face mask, etc.

In the event that your behavior does not comply with our client conduct policy, we reserve the right to discontinue providing services immediately. For the safety and well-being of our staff, clients, and patients, our conduct policy is strictly enforced. Non-compliance with our policy may result in corrective action being taken, which may include being asked to leave the property and the possible involvement of law-enforcement. We truly appreciate your cooperation and understanding and look forward to serving you.

By clicking here you have read and agree to Animal Vision Center's cancellation policy and terms

As your appointment time is reserved specifically for you, Animal Vision Center, LLC has a cancellation/no-show policy. Out of consideration for our patients, staff, and our doctors, we ask that you notify us 24 business hours in advance should you need to cancel or reschedule your appointment. Our business hours are Monday through Friday, 8:30am to 5pm. Messages left on Fridays or on weekends for Monday appointments do not qualify as advance notice because we do not retrieve those messages until Monday morning.

A “no-show” is when a client misses a scheduled appointment without cancelling it or providing 24 business hours notice of cancellation. In order to reschedule a missed appointment, you will be charged a missed appointment fee and be required to leave a NON-REFUNDABLE RETAINER equal to the amount of the initial consultation ($515) will be required ($235 for missed recheck appointments). This retainer amount will be credited toward the next appointment if that appointment is kept.

We do understand that unanticipated events happen occasionally; emergency cancellations are handled on an individual basis. As a courtesy, Animal Vision Center, LLC has email and voice reminder capability to help remind you about your appointment date and time; however, it does remain the client’s ultimate responsibility to keep track of scheduled appointments. We thank you in advance for abiding by these policies and helping us keep our patients, clients, and staff on schedule and safe!

Authorization*

I agree.

I authorize and direct the veterinarians at the Animal Vision Center to diagnose, prescribe, perform minor therapeutic procedures, that their judgement may dictate to be advisable for the patient’s well-being. No warranty or guarantee has been made as to the result or cure.

ALL FEES ARE REQUIRED TO BE PAID IN FULL UPON COMPLETION OF VISIT.

In the event any balance due hereunder is not paid as agreed, the undersigned jointly and severally agree to pay all cost included in said unpaid balance, including a reasonable collection and/or attorney’s fees.

Todays Date*

MM slash DD slash YYYY

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