Quality of Life Questionaire

Your Petner
Pet's Name*
Preferred Call name or nickname
DogCat
Date of Birth/Age of Your Pet - an estimate is fine
Breed & Color (If your cat is not a known breed, do they have long, medium or short hair?)
MaleNeutered MaleFemaleSpayed Female

What made you reach out to us? What are your goals and priorities for this consult?*

Share with us your understanding of "what's going on" with your Petner. What has been explained about their disease and what symptoms are you seeing?*
YesNo
Previous Veterinarian(s)
If None, Please Let Us Know That.
YesNo, I have them or will get them
Upload Previous Veterinary Records

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Please upload if available. Cancelof

What treatment options or therapies have been offered to you for your pet's condition. Please include those you are NOT interested in pursuing.

What current medications and supplements do you routinely give your Petner? Include anything orally and topically. Please include dose (mg or size) and frequency is to the best of your knowledge.
Feel free to upload pictures of the medications or supplements if that is easier.

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How easy is you Petner to Medicate? What struggles do you have administering their current therapies?

What does your Petner eat during the course of a normal day? What is your pets estimated food intake? Has there been any recent appetite changes? Are you having to hand feed or encourage eating?
Feel free to upload pictures of their diet if it is easier.

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I do not want further diagnostics and prefer to monitor my pet by outward symptoms and the quality of our PetnershipI am open to in home diagnostics only (this includes bloodwork, basic needle biopsies, etc)I am open to taking my pet to a traditional brick and mortar general practice veterinarian for things like radiographsI am open to taking my pet to a specialty center for advanced diagnostics such as ultra sounds.
Please feel free to expand on anything checked above
What are your "lines in the sand" with regards to stopping points for care? What things do you absolutely not want your pet to experience? ie - in ability to stand, wearing diapers, appetite decline, unable to sleep in certain area, etc.

Do you have any financial considerations or concerns of which we should be aware? If you have insurance for your pet please let us know here.

Time alone and travel - when considering end of life care petners often require additional time and consideration. Please let us know how long during the day your petner typically spends alone and if you have any upcoming travel where you will not be the one caring for your petner.

Fear Free Questions

As Fear Free Certified Professionals, we want to make your pet's veterinary experience as stress-free as possible.
Being approached by veterinary staffGetting on a scale for a waitBeing put up on a table for examinationHaving direct eye contact with technician or veterinarianHaving a rectal temperature takenUse of instruments such as stethoscope or otoscope (look in ears)Other
Feel free to further explain any of the above concerns for any specific Petner.
What are the sensitive areas that your pets do not like to have touched by you or others?
Do your pet have any favorite treats or foods we can make sure to provide during our visit?
Do your pets have any food/treat allergies or things we should avoid during our visit?
Does your pet enjoy toys? If so what kinds?
Has your pet ever been prescribed any supplements or medications to help with a visit with he veterinary team? If so what was it and what results did you experience?
Anything else you would like us to know?

Client Policies and Procedures

We want you to be aware of and understand the following policies and procedures for all clients.
YesNo
FINANCIAL POLICY:

We accept Visa, Mastercard, Discover, and American Express, Venmo, Zelle. We also accept cash.

In addition, we also offer several 3rd party financing options for our clients via Scratchpay, and Care Credit.

We are happy to work with you submit any needed insurance claims.

Full payment is due at the time of service. This includes any charges/fees agreed to by my authorized proxy. Our team is happy to provide any client with a written treatment plan prior to services being rendered. Your signature below indicates your agreement with these policies.
TREATMENT CONSENT:

By signing this document, I declare I am over 18, the lawful owner of all listed pets, and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of Petnership Veterinary Care to examine, prescribe for or treat the my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the except of another veterinary facility.
Signature (can be drawn with your mouse/track pad)*

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Client Information