Appointment Request

Appointment Request

This information will allow us to best prepare for your appointment. It must be completed before we will confirm an appointment date & time.
What is the reason for this appointment?*

Home Euthanasia
Preferred Appointment Day/Time:*

ASAP, anytime worksMorningAfternoon
Name*

First NameLast Name
Email*
example@example.com
Address for the Appointment*

Street Address

Apartment Number / Gate Code

CityState / Province

Postal / Zip Code
Cell Number for Calls/Texts*

Area CodePhone Number
Pet's Name*
Pet's Breed*
Pet's Birthday*
Estimate if Unknown
Pet's Weight: *
Primary Veterinarian: *
Specialty Veterinarian (if applicable):
Pet's current diet: name and amount, including treats. *
List all medications and supplements: name, dose (mg), and frequency.*
Primary Concerns:*

geriatric care (comfort, strengthening, etc)orthopedic (arthritis, muscle pain, etc)neurologic (IVDD, neck/back pain, etc)post-operative care
What are your goals for this visit?*

My pet is not yet ready for euthanasia; I'd like to discuss the medical history and possible additional options for care.My pet has a terminal illness; I'd like to discuss expectations for illness progression and ways we can manage the symptoms (hospice care).I'm not sure if my pet is ready yet; I'd like to discuss ways to measure quality of life and how to know when it is time.My pet will be ready for euthanasia in the near future; I'd like to discuss the process and make a plan.
Describe your pet's symptoms:*
When did you first notice these symptoms? Are they constant or intermittent? Does anything seem to make them better or worse (like rest or medications)?
Have any diagnostics been performed? What were the results? (Bloodwork, X-Rays, MRI, CT, etc)*
List any other medical conditions or surgeries (current and past): *
Please obtain and attach full medical records (including doctor's exams/notes and test results) from your primary and specialist veterinarians.

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What are your pet's needs for daily life and activities?*

Low - basic functions around the houseModerate - short to medium daily walksHigh - long walks, hikes, runsVery high - athlete or working dog
What are your wishes for aftercare?*

Home burialPrivate cremation with the ashes returnedCremation WITHOUT the ashes returned
Has your pet been nervous or grumpy with strangers, or at previous vet visits? *
Does anyone in your household have a potentially contagious illness (fever, cough, etc) or recent contact with anyone confirmed to have a contagious illness?*

YesNo
Is there anything else you'd like us to know?
About your pet, your goals for the visit, special requests, etc.
Include a favorite photo of your pet!

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Client Agreement

By requesting an appointment with Vet Around Town, I confirm:

I am the owner / authorized agent for the owner of the animal being evaluated. I am mentally competent, under no duress or the influence of drugs or alcohol, and am over the age of eighteen.

I understand that no guarantee is made regarding the outcome of any diagnostic or treatment performed. I understand that I have the right to decline any diagnostics/treatments recommended by the veterinarian.

I assume responsibility for all charges incurred in the care of this pet. Payment is due at the time of service; accepted forms of payment include all major credit cards and cash. Payment plans are not accepted other than through a third-party service called Scratch Pay.

I agree to the cancellation policy: A missed appointment or cancellation within 24 hours of the scheduled appointment time is subject to a charge equivalent to a basic housecall and a 45-minute consult.

I grant the right to use my pet's name and image for promotional materials in any social media, including but not limited to printed material, internet, and video.

If scheduling for acupuncture/laser therapy: I understand that these therapies are considered to be a type of Complementary and Alternative Veterinary Medicine (CAVM) according to the Texas Veterinary Board (§573.16). In our practice, it is offered as a plan of Integrative Medicine, meaning that it is used in combination with conventional veterinary medicine. It may be suggested as an adjunctive therapy (most commonly for pain management), and is NOT intended to replace conventional therapies. Complications of acupuncture are uncommon, and include, but are not limited to: broken needle under the skin, needle ingestion, infection, bleeding, nerve damage, pneumothorax. I understand the costs associated with any complication, including additional diagnostics, treatment, procedures, and surgery, that may arise from or during the diagnosis and treatment of my animal are not the responsibility of Vet Around Town.

Should I request, or it become necessary, to handle my own animal, I waive the option of legal action against Vet Around Town, its employees, students, and governing entities, in the event I am injured.
Client Agreement

By requesting an appointment with Vet Around Town, I confirm:

I am the owner / authorized agent for the owner of the animal being evaluated. I am mentally competent, under no duress or the influence of drugs or alcohol, and am over the age of eighteen.

I assume responsibility for all charges incurred in the care of this pet. Payment is due at the time of service; accepted forms of payment include all major credit cards and cash. Payment plans are not accepted other than through a third-party service called Scratch Pay.

I agree to the cancellation policy: A missed appointment or cancellation within 24 hours of the scheduled appointment time is subject to a charge equivalent to a basic housecall and a 45-minute consult.

Should I request, or it become necessary, to handle my own animal, I waive the option of legal action against Vet Around Town, its employees, students, and governing entities, in the event I am injured.
*

I have read, understand, and agree to the above statements.
Signature*

Clear
Please verify that you are human*
Should be Empty: