FPMVC Apt Request Form

Full Name*

First NameLast Name

Phone*

Area CodePhone Number

E-mail*

Do you prefer email or text for communication?*

EmailText

Pet’s Name *

Species*

DogCat

Breed

Age*

Service Required*

In-Home EuthanasiaCold Laser Therapy Session (if this is your pet's first session, Dr. Wagner will do a consultation including: performing a Physical Exam, reviewing your pet's medical history/diagnoses and making recommendations for laser treatment plans)Quality of Life Consult (this appointment is for pet parents who feel their pet’s day-to-day comfort and wellbeing is declining; Dr. Wagner will perform a physical exam, review your pet’s medical history and have an in-depth discussion with you regarding her analysis of Quality of Life. An individualized treatment plan will then be developed for your pet which can include pain control medication or hospice care.)Integrative Medicine Consult for Senior Pets (this appointment is for geriatric dogs and cats OR patients with terminal illnesses. Dr. Wagner will review your pet’s medical history, perform a physical exam and make recommendations for care incorporating integrative medicine treatments. Such treatments can include: supplements/nutraceuticals, Chinese herbal medicine, essential oils/aromatherapy, medicinal mushrooms, Cannabis products, Cold Laser Therapy, Targeted Pulsed Electromagnetic Field Therapy/Assisi Loop, massage and more!)

Approximate Weight (lbs.)*

Does your pet require any special handling for aggressive behavior? Please explain.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

What time works best for you?*

MorningAfternoonEvening

Any additional info you'd like us to be aware of?

Appointment Request