CV House Vet - Euthanasia Consent Form

1
Email* This field is required.
example@example.com
2
What is your first and last name? * This field is required.
First Name
Last Name
3
What is your pet's name?* This field is required.
4
COVID 19 Screening Questions
5
1. Do you or anyone in your household have any flu-like symptoms such as* This field is required.
Cough
Shortness of breath
Sore throat
Runny nose
Difficulty swallowing
Hoarse voice
Change in smell or taste
Nausea or vomiting
Unexplained fatigue
Malaise
Chills
Headache
None
6
2. Have you or anyone in your household travelled inside or outside of Canada in the past 14 days?* This field is required.
Yes
No
7
3. Do you or anyone in your household have a fever?* This field is required.
Yes
No
8
4. Have you or anyone in your household had close contact with anyone with a respiratory illness?* This field is required.
Yes
No
9
5. We kindly ask you to remain inside OR social distance and wear a mask when we perform procedures on your pet. Please select yes if you understand this statement.* This field is required.
Yes
No
10
1. Tell us how he/she has been doing. * This field is required.
11
2. Please describe any concerns.* This field is required.
12
3. How is his/her appetite?* This field is required.
13
4. Describe everything that he/she eats in a day and how much.* This field is required.
14
5. Has there been any of the following* This field is required.
Vomiting
Diarrhea
Coughing
Sneezing
Itching/chewing at skin, paws or ears
Limping, lameness or stiffness
Inappropriate urination (accidents)
NONE
15
If you selected any of the boxes in question 5, how often are these occurring?
16
6. Tell me about his/her daily routine* This field is required.
17
7. What is his/her activity like?* This field is required.
18
8. Have there been any sleep disturbances?
Yes
No
other
19
If Other, Please Specify
20
9. What makes him/her happy?* This field is required.
21
10. How do you know when your pet is upset?* This field is required.
22
11. What are your expectations from us for this appointment?* This field is required.
23
12. Please tell us about anything we forgot to ask about.* This field is required.
24
COVID-19 Protocols

Appointment times will be more broad and approximate than previously. We appreciate your patience during this time.

As per current research, it has been recommended to limit contact with others to a maximum of 15 minutes while wearing a mask: https://www.publichealthontario.ca/-/media/documents/ncov/main/2020/09/covid-19-contact-tracing-risk-assessment.pdf?la=en. With this in mind, we will be minimizing our interactions and time spent in-person at each appointment. To ensure comprehensiveness of your pet's medical exam, we will be discussing any details over the phone prior to and/or after their appointment as needed.

We will not work if we are sick at all.

Appointments will only take place outside and so may be postponed due to inclement weather. If you are not comfortable with outdoor appointments we ask that you not book at the present time. We will spend as little time on your property as possible.

We ask that if possible you stay inside during the appointment. If this is not possible please wear a mask and distance yourself from our team as we work with your pet. We will wear appropriate PPE.

We will only bring what is absolutely necessary for your pet to the appointment and disinfect all tools thoroughly between each appointment.

We will send an estimate outlining our current plan prior to the appointment and we ask that you pay us with contactless payment E-transfer or credit card number over the phone the day before the appointment. We will adjust any changes, eliminations or additions to the plan the following day and refund or charge as appropriate.

We will perform required procedures on your pet and may discuss findings and plans while social distancing or over the phone to reduce risk of COVID-19.

We will provide you with electronic paperwork where appropriate.

Thank you for your patience and respect during these unprecedented times,

Caledon-Vaughan Veterinary House Call Services Team
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