New Patient Form

New Patient Form

Please complete this form so we can get to know you and your pet better.
Name*

First NameLast Name
Email*
This email is used to send you a Zoom invite for the initial Telemedicine Consultation
Cell Phone Number*

Area CodePhone Number - This number can be used for a FaceTime initial Telemedicine Consultation
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Pet's Name*
Age / Date of Birth
Sex / Gender*

MaleMale NeuteredFemaleFemale Spayed
Species*

DogCatOther
Breed*
Dog or Cat Breed (DSH = Feline Domestic Short Hair; DLH = Domestic Long Hair)
Weight (Approximate)*
Weight: Pounds or Kilograms?*

Pounds (Lbs)Kilograms (Kgs)
Please list the Veterinary Hospitals that your pet has attended over the last 2 years
We will notify your regular veterinarian following euthanasia
Please inform us of any Medical Conditions and any current Medications / Supplements given
What is your pet's current status? For example: "We are facing a crisis, and need an in-home visit shortly." Or: "We are pre-planning and are in a palliative / watch-and-wait stage."
Please let us know the best time and day to schedule the initial consultation. Our normal hours are 12 noon - 6 PM Monday to Saturday.
Best Time and Day for Initial Telemedicine Consultation:*
We will try our best to accommodate your requests
Do you prefer Zoom or FaceTime for initial telemedicine consult with Dr. Speizer?

ZoomFaceTimeOther
The next step after submission of this form is to Pre-Pay for the initial Telemedicine Consultation with Dr. Speizer. Cost of this consultation is $125.00 + HST = $143.75.

Please click the "Pay for Initial Telemedcine Consult" Link on the following Thank-You page. It connects you to KindHearted Pet Euthanasia's Cart to pay for the initial Consultation.
Other Information to share with Dr. Speizer
Please verify that you are human*
KindHearted Pet Euthanasia

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New Patient Form

KindHearted Pet Euthanasia