Heartland Home Veterinary Care Client and Patient Information sheet

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 NameLast Name
Address for appointment*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this your mailing address as well?*

YesNo. 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?
Preferred method of communication

CallTextEmail
Level of urgency for appointment

Same day if possibleNext daySame weekUnsure/near futureOther-enter specific details here:
Pet name*
Species of pet (cat, dog, etc).*
Breed*
Pet's Age (can add birthdate if known)*
Pet's sex *
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?*

YesNo
Is there someone in the home who can help the veterinarian carry the pet on a stretcher to her vehicle if needed?*

YesNoN/A
Do you know what aftercare option you will be selecting for your pet?*

Home burialPrivate cremation through Heartland Home Veterinary Care (ashes returned)Communal cremation through Heartland Home Veterinary Care (ashes not returned)UndecidedOther
We now offer Euthabags for home burial. These are leakproof, zippered bags made with recycled materials. These provide a dignified, eco-friendly alternative to plastic, ensuring your pet can be transported and laid to rest with care and cleanliness. If you would like to purchase one, please select the appropriate size:

X-Large (85-190lbs): $40Large (40-85lb): $30Medium (20-40lb): $25Small (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.*

YesNoUndecided
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?
Should be Empty: