APPOINTMENT REQUEST FORM
Name
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Do you prefer contact through phone, text, or email?
Please Select
Phone call, please!
Texting is preferred
Emailing is preferred
Any is OK!
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is there reliable internet access at your address? Our software and electronic payment system may require internet access.
Please Select
Yes, there is reliable service in my area.
Poor or unreliable service; but wi-fi is available.
Poor or unreliable service, NO wi-fi available.
Is there reliable internet access in your neighborhood? (our veterinary software is Cloud based)
Yes, there is good cell/internet service in my neighborhood.
Poor service, but Wi-Fi is available at my house.
Poor service, NO Wi-Fi available
What services are you interested in? (check all that apply)
Wellness Exam
Vaccinations
Evaluation of medical problem (allergies, illness, arthritis, check lump, etc.)
Minor procedures (nail trim, express anal glands, ear cleaning, fluid administration)
Behavior Exam
Euthanasia
Other
Are you wanting a housecall or office visit?
Please Select
Housecall
Office visit
Either is OK.
Please describe any specific reasons for making this appointment:
Do you know what date(s) or time(s) you would like to schedule an appointment?
Your Pet's Name:
Your Pet's Species:
Please Select
Dog
Cat
Rabbit
Rat / Mouse
Guinea Pig
Hamster
Other
Your Pet's Sex:
Please Select
Intact male (not neutered)
Intact female (not spayed)
Neutered Male
Spayed Female
Unknown
Your Pet's Size
Please Select
Under 5 lbs.
6lbs to 10lbs
11lbs to 20lbs
21lbs to 40lbs
41lbs to 60lbs
61lbs to 80lbs
81lbs to 100lbs
101lbs to 120lbs
120+lbs
Your Pet's Age (you can type a birth date or an approximate age):
Your Pet's Breed(s):
Your Pet's Color(s):
List your other pet(s) here --> Put their: Name, Species, Sex, Size, Age, Breed(s) and Color(s):
Upload any photos of your animals that would be pertinent to this appointment request!
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