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 Euthanasia for a Cat or DogCold 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.)

Approximate Weight (lbs.)*

For Euthanasia Requests, please acknowledge the following information: Family Paws Mobile Veterinary Care does not provide aftercare services of your pet’s body. It is your responsibility to make such arrangements prior to Dr. Wagner’s arrival. We recommend 2 local pet crematoriums; their information is listed on our webpage www.fpmvc.com. (Click the “Service Area & Pricing” Tab). :*

I acknowledge that I am responsible for my pet’s postmortem care. The two most popular types of postmortem care are: cremation and burial.I am requesting a different service (consultations or cold laser therapy).

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?*

MorningAfternoon

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

Appointment Request