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 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).
*
Please list everything your cat is eating including amounts and frequency.
*
Please describe any other concerns you'd like to discuss with the doctor, or you can give more detail on a concern.
*
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)
Submit
Should be Empty: