Appointment Request Form

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Are you requesting one of the below services;* This field is required.Home Euthanasia Pet Hospice/Palliative Care Pain Management (acupuncture, laser therapy) Quality of Life Consultation (Virtual Tele-Advice Consultation)
Yes
No
2
Please let us know which service you are requesting* This field is required.
In-Home Euthanasia
Pet Hospice/Palliative Care, Pain Management (Laser Therapy, Acupuncture)
Quality of Life Consultation (Virtual Tele-Advice Consultation)
3
The past two years have presented many challenges locally and worldwide. I am proud and happy to have been able to provide veterinary care for so many pets in my community throughout 2020 and 2021. I am grateful for every one of my clients that entrusted their beloved companions in my care. Thank you.

Moving forward, House Call Vet RVA will only be providing hospice & palliative care and end-of life services.

I want to thank the members of my community that are inquiring about wellness home visits and sick pet visits. I feel honored and thank you for your interest.

Sincerely,
Kaitlyn Hemsley, DVM
House Call Vet RVA
804-382-3684
info@housecallvetrva.com

01/01/2022
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Name* This field is required.
Prefix
First Name
Last Name
5
Email* This field is required.
example@example.com
6
Phone Number* This field is required.
Please enter a valid phone number.
7
Can you receive text messages at this number?* This field is required.
Yes
No
8
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
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The Bahamas
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Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Germany
Ghana
Gibraltar
Greece
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Jamaica
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Laos
Latvia
Lebanon
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Liberia
Libya
Liechtenstein
Lithuania
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Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Pet’s Name* This field is required.
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Species* This field is required.
Canine
Feline
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Breed* This field is required.
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Color* This field is required.
13
Sex* This field is required.
Male
Female
Male, Neutered
Female, Spayed
14
Date of Birth * This field is required.
Patient’s Date of Birth
Month
Day
Year
15
Pet’s Weight (in pounds)* This field is required.
Patient’s Weight (in pounds)
16
Who is your pet’s current veterinarian? * This field is required.
Primary Veterinary Clinic
17
Please tell us a little about what is going on?* This field is required.
18
Please use the space below to share the names of any family and/or friends that will be present. *This is not required and the information will only be used to help make your pet’s appointment a more personable experience.
19
How did you hear about us?* This field is required.
20
Aftercare Request* This field is required.
Private cremation with return of ashes
Communal cremation with no return of ashes. My pet's remains will not be retuned to me.
Home burial. I wish to keep my pet's body at home for my own burial.
21
Please let us know the preferred day you would like to make your appointment for?* This field is required.We do our very best to accommodate every request. Please note, additional fees may apply to same-day requests, same-day weekend requests and on certain holidays.
Sunday
Monday
Friday
Saturday
22
Please choose an alternate day
Sunday
Monday
Friday
Saturday
23
Today's Date* This field is required.
Date
Year
Month
Day
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