Cardiology- Owner Scheduling Form

  • Cardiology Scheduling - Intake Form

    This form is intended for pet owners. Please fill out this form to schedule your Cardiology appointment at our Outpatient Imaging Center. If you have an URGENT Cardiology need or have further questions prior to booking please call 360-523-2650.
  • Date of Scheduled Appointment*
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  • Does anyone in the household have a nut allergy? (Occasionally we use peanut butter to distract patients)
  • Is your pet exhibiting any of the following clinical signs: (If so, we are not the place for your pet, please go to the emergency veterinarian)*
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  • Photo release: I allow South Sound Veterinary Imaging to take photos of my pet. Photos may be shared on social media or used for other forms of marketing.*

  • I hereby authorize the cardiologists of South Sound Veterinary Imaging, all of their affiliates, and their respective employees, agents, contractors, and representatives (collectively the “Medical Professionals”) to administer treatment as is considered therapeutically and/or diagnostically necessary.

    I authorize medical treatment, as well as possible alternative modes of treatment, as explained to me by the Medical Professionals. I further authorize interventional procedures of an emergency nature, if deemed necessary.

    The deposit is non-refundable if I cancel my appointment less than 48 hours before scheduled appointment. For those eligible for refund, a service fee ($8) will be subtracted from refundable amount.

    I give my permission to release case/patient information and/or photos so they may be used in teaching, continuing education, website, veterinary literature, and the like while patient confidentiality will be maintained.

    I consent to the release of all of my medical information to South Sound Veterinary Imaging, my provided veterinarian and affiliates.

    I assume full financial responsibility for all charges incurred for the care and treatment of this patient. Unpaid balances over 30 days will accrue an interest rate charge of 2% per month. I understand that if collection action should become necessary for recovery of any monies due under this contract, I agree to pay any and all collection costs up to 40%, court costs, and reasonable attorney fees.

    Information provided by me is solely for the use of the Practices and for any practice which hereafter begins performing veterinary services at the same premises as conducted by the Practices or in conjunction with the Practices.

    I certify that I am at least 18 years of age and have the authority to make decisions on behalf of the patient.

  • Continue to give your pet water and food as normal prior to the exam.

    Please give all medications as directed and prescribed by your veterinarian.

    Please bring the medications with you to the appointment.

    If your pet is taking any medication that you are uncertain should be given the day of the procedure, please contact your primary veterinarian for advice.

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