First Appointment Request Form
Please fill out this form with your information and we will get back to you. If your request is urgent please email or call as well to ensure we have seen your message. NB. This is not an emergency service and if I am unable to attend you will have to be seen by a bricks and mortar practice in an emergency.
Your Details
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are there any issues with locating your property? Please leave any relevant info here if so:
Parking is:
Readily available, on street
Please park on the driveway
Parking is by visitor permit which we will provide
You will need to pay to park here (meter parking, multi-storey etc)
Other
What is the reason for your visit request?
Palliative Care
Chronic Illness Management Including Mobility Issues
Quality of Life Assessment
Pre-euthanasia Consultation (in person)
Pre-euthanasia Consultation (online)
Other
What is your requirement at this stage?
I require an urgent appointment over the next few days
I require an appointment, but it is not urgent
I am registering in advance, I will be in touch when I need an appointment
I have already made an appointment, I'm just leaving you my details
I am registering to receive information about your services for now, I don't need an appointment
How did you hear about us?
Google
Vet referral
Recommendation
Other
Pet's Details and Information
Pet's name
Species
Cat
Dog
Pet's age or date of birth
Breed and approximate weight (if known)
Sex
Male
Female
Any behavioural or handling issues we need to be aware of? Will we need to bring an assistant to help with our examination?
Neutered?
Yes
No
Pet's current illness or symptoms?
Any current or recent medications?
What veterinary practice is your pet registered at? (if they are not, type N/A)
When was your pet last seen by a vet? (if they have not, type N/A)
May we obtain your pet’s medical history from your current vet?* (PLEASE NOTE THIS IS A REQUIREMENT AND YOU MUST BE REGISTERED WITH A VET PRACTICE)
Yes
No, I would prefer not
Not registered with another vet
Is your pet insured?
Yes
No
If yes, who is your pet insured with?
Please confirm you understand this is not a 24/7 service - and out of hours, or when I am unavailable, you will need to visit a 'bricks and mortar practice' in an emergency
*
I confirm
Data Protection: We will use the information you give us exclusively for the purpose of registering with Pets At Peace
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Please Opt in to having your details held by us
Please read and agree to our Terms and Conditions and Privacy Poiicy
*
I agree
Please verify that you are human
*
Submit
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