New Patient Appointment Form - PAWSific NW Mobile Vet

PAWSific Northwest Mobile Vet www.pawsificmobilevet.com

Thank you for your inquiry! We are thrilled to be able to help your pet!!! Please help us by completing this form so we can best accommodate you and your pet's needs. Please allow 2-3 business days for a team member to respond to your request, and to determine if we can provide services to your area! For in person visits - we are currently servicing the Federal Way and surrounding regions. At the forefront of veterinary medicine, we can now provide virtual telehealth visits! An estimate will be provided after an appointment request is scheduled. Please contact us directly at info@pawsificmobilevet.com or 206-395-6855 if you have additional questions. www.pawsificmobilevet.com
Telehealth

A telehealth video consult can be arranged with our veterinarian virtually, in the comforts in your own home, Please note - due to Washington State laws, an in-person exam on your pet within 1 year is required to diagnose and for prescription medications.
Are you interested in a video consult?*
Pricing

A full mobile concierge in-home exam and consultation is $125, and associated travel fee is $80-98 (subject to change and travel fees will be dependent on zip code/location). An estimate will be made for further treatments, testing, and medication based on our recommendations after the consult. If you are a new client, a deposit of the initial exam/travel fee is required to secure your appointment and a payment online link will be sent to you after we confirm your appointment. As we are a mobile service, please reschedule or cancel within 24 hours so we can arrange schedules accordingly. *Please note that you will be only charged one travel fee if you have multiple pets.
Client Information

Please fill out the following information about yourself so we can get to know you!
Full Name - Primary Contact*
Primary contact
Gender*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail Address - Primary Contact*
Phone Number - Primary Contact*

Area CodePhone Number
Can we text?*
Date of Birth

MonthDayYear
Secondary Contact or Emergency Contact

Please include a secondary contact or emergency contact for your pet
Full Name - Secondary or Emergency Contact*
Secondary contact
Relationship to owner*
Authorized to make medical decisions?*
Gender
E-mail Address - Secondary Contact*
example@example.com
Phone Number - Cell*

Area CodePhone Number
Can we text?*
Date of Birth

MonthDayYear
Patient Information

PAWSific Northwest Mobile Vet - Please fill out the following information so we can get to know more about your pet! If you have more than 1 pet, please complete a separate form.
Patient's name*
Primary contact
Species*
Breed*
Gender*
Date of Birth*

MonthDayYear
Weight (lbs)*
Please approximate if not known
Reason for Appointment & Info

Please let us know why you wish to schedule an appointment for your pet, and more information so we can get to know your pet better!
Reason for appointment & any concerns?*
Current Diet/Food & Treats*
Please describe the brand and frequency you are feeding your pet
Current Medications, Preventatives & Supplements*
Please indicate dose and frequency
Medical History *
What should we know about your pet?
Any vomiting, diarrhea, coughing, sneezing?*
Yes or no. If yes - please describe.
Please describe your pet's behavior with veterinary care?*
When was your pet's last visit with a veterinarian *
Month/year
Up-to-date on vaccines?*
Dogs: Core vaccines: Rabies, DHPP/DAPP (distemper/parvo). Optional yearly vaccines - Bordetella, Leptospirosis. Cats: Rabies, FVRCP. FeLV if indoor/outdoor.
Past hospitals - please list the names of the all the hospitals your pet has visited in the past so we can obtain records including vaccine records, if relevant.
If you wish - please upload a picture of your pet

Browse Files

Cancelof
Appointment Time Requested

Please choose an appointment time requested - this is NOT a confirmation. We will try our best to accommodate your time & date request.
Appointment Date Requested - First Choice*

MonthDayYear
Date
Appointment Date Requested - Second Choice*

MonthDayYear
Date
Please provide any additional scheduling requests and we can do our best to accomodate
Signature - I confirm that all the details are accurate and agree to the financial policy (see below)

Clear
Today's date*

MonthDayYear
Date
Photo/Video Release
I hereby grant PAWSIFIC NW Mobile Vet permission to take photos and/or video of my pet and/or myself, and to publish those images, with or without my name and/or my pet’s name, for any lawful purpose, including but not limited to, their website, social media accounts, and promotional materials, either digital or in print, in perpetuity. I waive any rights of compensation associated with the use of my/my pet’s image(s) and name(s) for the purposes outlined above.
Photo/video release*
Financial Policy
PAWSIFIC NW Mobile Vet requires payment in full at the end of your pet’s examination. An estimate will be provided for treatments, services and medications before they are performed.

Payment Options:
You can choose from: Check, Credit Cards
Pawsific NW Mobile Vet charges $40.00 for returned checks.

Additional Policy Information:
For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.

Cancellation Policy:
We ask that our clients give us 24 hour notice if they will be unable to keep their appointment. We understand that there are times when 24 hour notice is not possible.

New Client Appointment:
· We require a deposit equal to the exam & travel fee to hold the appointment.
· Since we are a fully mobile practice, we appreciate your cooperation to deterimine our travel route and scheduling.

· This deposit is fully refundable if the appointment is cancelled with a minimum of 24 hours notice.
· If the appointment is rescheduled with a minimum of 24 hours notice, the deposit will be transferred to the new appointment time.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.
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PAWSific Northwest Mobile Vet www.pawsificmobilevet.com

Telehealth

Pricing

Client Information

Secondary Contact or Emergency Contact

Patient Information

Reason for Appointment & Info

Appointment Time Requested

Photo/Video Release

Financial Policy