CV House Vet - Palliative Intake Form

1

Pet Owner Information

Name

Address

Telephone number

Email

2

Patient Information

Name

Species

Breed

Colour

Date of Birth or age

Sex

Spayed or Neutered?

Last Weight

3

Primary Care Veterinarian

Veterinarian

Clinic

Phone number

Email

4

Specialist Care Veterinarian

Veterinarian

Clinic

Phone number

Email

5

Even if there is no cure or if your beloved pet is nearing the end of his/her life hospice/
palliative care can maximize the amount of quality time you have with your pet. We look
forward to helping your pet feel more comfortable in this time of need.

In order for us to give you the best possible care we would appreciate your responses to
the following questions.

6

Diagnosis

What is your understanding of your pet’s condition?

7

Caretaker Information

What are your daily challenges?

What are your expectations from our team? How can we help?

8

Main Concerns

What are your main concerns?

What would you like us to focus on?

9

Some Questions about your pet

What role does your pet play in your life?

Does your pet have any diagnosed medical problems?

Is you pet on any medications?

Is your pet on any supplements?

What does your pet eat?

Does PATIENT have any gain or loss of weight?

What kind of environment does your pet spend time in and is it appropriate and manageable for your pet?

10

Do you have interest in

Keeping a daily calendar?

Further diagnostics?

Hospital treatment?

11

Future Planning

Do wish to have any other potential team providers involved? (ie Nurse, other veterinarians, Social Workers. Clergy, respite workers?)

Do you have any future travel plans?

Who are your emergency contacts?

Do you have aftercare/memorial wishes?