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About
Clients
Referring Veterinarians
- Referral Form
Contact Us

(503) 567-8835

Minimally Invasive Specialty Center for Animals

19056 Willamette Drive
West Linn, OR 97068

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New Client Form

Minimally Invasive Specialty Center for Animals

New Client Form

Thank you for choosing MISCA for your veterinary specialty needs. We look forward to serving you and your pets.

All required fields are marked [*]

"*" indicates required fields

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Primary E-mail Address (for reminders, newsletters, Petdesk access):

Primary Contact Phone:*

Cell

Work

Home

Cell Phone

Work Phone

Home Phone

Alternate/Secondary Contact:

Alternate/Secondary Contact Phone:

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Cell Phone

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Home Phone

List all veterinary clinics your pet has been seen at:

Patient Information

Pet Name*

Approximate Age/Birthdate:*

Sex:*

Male

Female

Spayed/Neutered:*

YES

NO

Species:*

Breed:*

Color:*

Pet Insurance Provider and Policy Number:

Please provide a brief explanation of reason for contact:*

Image Consent: We often use patient pictures for our website, Facebook, and Instagram. Your signature authorizes MISCA to use photographs and videos in print media, brochures, the MISCA website, and on social media outlets. You also agree not to file any claim for revenue, or lawsuit for damages, against this veterinary practice with respect to the release of this information.*

I consent

I opt out

As a pet guardian, you will be held liable for the financial responsibility of services that are performed for each pet.*

I accept financial responsibility

"No Show" / Cancellation Policy: At the time of scheduling a $50.00 deposit is required - this cost will go towards the overall cost of care and is not an additional fee but is forfeit by the client if the client does not show up for their appointment or cancels without at least a 24 hour notice.*

I understand and accept

I agree to indemnify and hold MISCA harmless from and against any and all liability arising out of the performance of any procedure. I understand that some risks always exist with anesthetic procedures, and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before these procedures are initiated. Should some unexpected life-saving emergency care be required and the attending veterinarian be unable to reach me, the staff has my permission to provide such treatment, and I agree to pay for such care.*

I agree and understand

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Minimally Invasive Specialty Center for Animals

MISCA

19056 Willamette Drive West Linn, OR 97068

(503) 567-8835

MISCA is a cutting edge referral-based specialty center based in Portland that is dedicated to collaborative and innovative small animal veterinary medicine.

https://MISCAspecialtyvet.com/

HOSPITAL AFFILIATIONS

American Veterinary Medical Association
Oregon Veterinary Medical Association
VIRIES
Portland Veterinary Medical Association
American College of Veterinary Internal Medicine

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