Quality of Life Questionaire

  • Client Information

    This form has several sections, the more information you are able to provide the more we can assist you in this challenging time.

  • IMPORTANT:

    If your pet has any specific behavior concerns please feel free to reach out directly to discuss your concerns. We want everyone to have a fear free low stress opportunity to receive needed health care.
  • Have we visited with your family previously?
  • Has any of the following information changed since we have seen last?
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  • How Would You Prefer To Be Contacted?
  • Is There a Spouse/Partner/Family Member Who Should Be Listed On Your Account?
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  • If you are unavailable or in case of emergency...

  • Is there anyone else (besides above listed contacts) who should be listed on your account, who has ongoing permission to make medical decisions for your pet(s)? ie, pet sitters, other family members, close friends, etc
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  • Your Petner

  • Species*
  • Sex*
  • Have you visited any other veterinarians in the past?
  • Would you like us to attempt to get those records for review?
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  • Future diagnostics - Often repeat bloodwork, imaging, and/or other tests can help track patient status and disease. What is your current interest in additional testing to monitor your Petner's disease? (check all that may apply)
  • Is your family considering euthanasia during this consult if it is determined to be appropriate at this time?

  • Fear Free Questions

    As Fear Free Certified Professionals, we want to make your pet's veterinary experience as stress-free as possible.
  • Check any situations listed below that your pet has shown avoidance or dislike of in the past.

  • Client Policies and Procedures

    We want you to be aware of and understand the following policies and procedures for all clients.
  • Petnership Veterinary Care uses email, text and our medical records systems for communications regarding our patient's reminders for health care needs. Do we have your permission to contact you via email, text and/or our app regarding these reminders?*

  • 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.

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