• 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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    2 digit month, 2 digit day, 4 digit year
  • Time of Scheduled Appointment*
  • 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 veterinarians of South Sound Veterinary Imaging, all affiliated entities, and their respective employees, agents, contractors, and representatives (collectively, the "Medical Professionals") to perform diagnostic procedures that are considered medically appropriate to evaluate my pet's condition. This authorization includes consented sample collection (including, but not limited to, blood, urine, cytology, and fine-needle aspiration samples when clinically appropriate) and other diagnostic tests deemed necessary to establish a diagnosis or guide treatment recommendations.

    I understand that any non-emergency therapeutic treatment or intervention will be discussed with me by a Medical Professional before it is performed, and my authorization will be obtained prior to proceeding.

    If my pet experiences an unforeseen medical emergency during evaluation or diagnostic procedures and immediate intervention is necessary to prevent undue suffering, serious deterioration, or death, I authorize the Medical Professionals to provide emergency treatment without prior consultation if they determine that delaying treatment would not be in my pet's best interest.

    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 ($15) 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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