House Call Acknowledgement Form
Name
*
First Name
Last Name
Pet's 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.
Format: (000) 000-0000.
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 restricted area with no available hiding spots (such as a 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 acknowledge that if I am not home OR the address listed above is not correct when the veterinarian arrives for the housecall appointment, that I will still be responsible for paying the housecall fee and will have to reschedule the appointment.
*
I agree.
I understand this this form needs to be submitted 48 hours prior to the appointment time or the house call will be cancelled.
I agree
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What would you like accomplished by the completion of this appointment?
*
Please list any medication or supplements your cat is taking (including parasite prevention). Do you need any refills?
*
Please list everything your cat is eating including amounts and frequency.
*
Please describe your health or behavior concerns you'd like to discuss with the doctor with more detail.
*
Please check any health or behavior concerns you would like to discuss with the doctor.
*
Sneezing
Coughing
Vomiting, including hairballs, more than once a month
Changes in urination (more or less than normal)
Constipation
Loose stool
Appetite changes
Weight loss or gain
Behavioral changes
Bad breath or dental concerns
Changes in activity level
Skin, ear or toenail concerns
Other (please describe below)
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Would you like us to perform a nail trim today? ($27)
Would you like to update vaccines today?
Please be aware that our doctors recommend flea prevention for all cats, regardless of indoor only status. Although fleas can't live on humans, they can jump on us and use us as a vehicle to get in to your home. They can create itching, severe skin irritation in allergic cats, can pass tapeworms on to your cat, and even serve as a way of transmitting cat scratch fever to humans. Would you like to further discuss flea prevention at your appointment?
Blood Pressure Screening - We recommend testing all cats 7 years of age or older for high blood pressure (hypertension). Just as in humans, high blood pressure may not show clinical signs until it causes significant, irreversible damage to the eyes (retinal detachment and/or detachment), brain (strokes), and heart (muscle thickening). Measuring blood pressures in cats is not as easy as in humans - we use a machine specially designed to measure blood pressure in animals with very small blood vessels. We only pay attention to the top value (systolic blood pressure) since other values cannot be obtained accurately. Hypertension can be easily treated in cats with daily medication. ($42 charge for this service). Would you like us to perform this service?
Senior Wellness Blood Panel - This comprehensive blood panel tests for diabetes, kidney disease, liver health, thyroid balance, protein and electrolyte levels, and cardiac health. Abnormalities in any of these levels can help us diagnose disease processes early, before they start to affect your cat's health. Often instituting treatment at this stage can provide much improved quality and quantity of life than if the same disease is diagnosed at a later stage. ($228 charge for this service). Would you like us to perform this service?
Urinalysis - Kidney and bladder issues are very common in older cats. Checking a urine sample for urine concentration, protein level, white and red blood cells, and bacteria can help us find these issues and allow us to keep your cat comfortable and healthier in their senior years. ($79 charge for this service). Would you like us to perform this service?
Our doctors recommend an annual intestinal parasite screening to be sure your cat is healthy! Please bring in a fresh (within 12 hours of leaving your cat's body) fecal sample in a plastic bag or closed container. It is fine if it has kitty litter on it. We only need about a large grape-sized amount of stool. The cost to send out this test is $64. Would you like us to perform this service?
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