House Call Acknowledgement Form
Name
*
First Name
Last Name
Address for House Call Appointment:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Best phone number for us to reach you on the day of your appointment:
*
Please enter a valid phone number.
Preferred Pronouns (optional)
We perform house calls to help decrease the stress levels of our patients and clients. As you can imagine, these visits to require more time (for both veterinarian and technician) in addition to gasoline costs than in-office appointments. For these reasons, we need you to agree to the following conditions before we will come to your house.
By checking below, I acknowledge and understand that if I am unable to confine my cat to a small bathroom prior to Purrfect Care's arrival at my home, and the veterinarian is not able to examine my cat without undue stress, the appointment will be rescheduled. I am still responsible for paying the housecall fee.
*
I agree.
By checking below, I confirm that I or any member of my household has not experienced any illness symptoms in the past 48 hours. For everyone's health and safety, if we arrive for your appointment and you and/or a member of your household is showing illness symptoms, we will charge a house call fee and reschedule your appointment.
*
I agree.
Submit
Should be Empty: