Heartland Home Veterinary Care Client and Patient Information sheet
Dr. Decker will contact you within 24 hours to meet, go over things, and set up an appointment.
Full Name
*
First Name
Last Name
Address for appointment
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this your mailing address as well?
*
Yes
No. Please provide one below:
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Is it okay to text this phone number?
Please Select
Yes
No
Preferred method of communication
Call
Text
Email
Level of urgency for appointment
Same day if possible
Next day
Same week
Unsure/near future
Other-enter specific details here:
Pet name
*
Species of pet (cat, dog, etc).
*
Breed
*
Pet's Age (can add birthdate if known)
*
Pet's sex
*
Please Select
Male-neutered
Female-spayed
Male-intact
Female-intact
Pet's color/markings
Pet's weight in pounds
*
Please describe the problems your pet is having or quality of life concerns.
*
Please list any medications or supplements your pet is taking.
Does your pet experience any aggression or anxiety around strangers, veterinary staff, or anyone coming into your home? If yes, please explain.
*
*Some pets require medications prior to their appointment if aggression could be a concern.
How is your pet's appetite?
*
What questions do you have for us?
For legal purposes, has your pet bitten anyone in the last 10 days?
*
Yes
No
Is there someone in the home who can help the veterinarian carry the pet on a stretcher to her vehicle if needed?
*
Yes
No
N/A
Do you know what aftercare option you will be selecting for your pet?
*
Home burial
Private cremation through Heartland Home Veterinary Care (ashes returned)
Communal cremation through Heartland Home Veterinary Care (ashes not returned)
Undecided
Other
We now offer Euthabags for home burial. These are leakproof, zippered bags made with recycled materials. These help to ensure that your pet can be transported and laid to rest with care and cleanliness in a dignified manner. If you would like to purchase one, please select the appropriate size:
X-Large (85-190lbs): $40
Large (40-85lb): $30
Medium (20-40lb): $25
Small (3-20lb): $15
Would you like us to create a clay paw print as a memorial for your pet? This keepsake is $40.00 and can be carefully made in your home at the time of your appointment or through aftercare services.
*
Yes
No
Undecided
Who is your pet's regular veterinarian? Would you like us to contact them to inform them of your pet's passing?
How did you hear about Dr. Decker and Heartland Home Veterinary Care?
Sedation: Route given ___________
Rows
Ketamine
Butorphanol
Xylazine
Acepromazine
Midazolam
Tzed
Amt (ml)
Euthanasia: Route given ___________
Rows
Euthaphen
Amt (ml)
Any concerns? Questions to ask owners? Thoughts or notes?
Submit
Should be Empty: