Appointment form for a Comfort Care, Quality of Life, Acupuncture
We understand this is a difficult time for your family, we appreciate all the information you can provide as it will be sent to Dr. Phillips directly as well as the hospital.
Please select the appointment type
*
Please Select
In-home comfort care (palliative care)
Quality of life
Acupuncture
Date
*
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Contact number
*
Please enter a valid phone number.
Secondary Name
First Name
Last Name
Secondary Contact Number
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet's name
*
Species
*
Please Select
Dog
Cat
Small mammal
Sex
*
Please Select
Male
Male, neutered
Female
Female, spayed
Unknown
Color
*
Age or birthdate
*
Current weight in pounds
*
Briefly describe the reason you are seeking care:
*
Current veterinary hospital(s) and/or veterinarian(s)
*
Does your pet have any fearful or aggressive behavior towards strangers?
*
Please Select
Yes
No
If so, please briefly describe the behavior below:
I consent to services provided in my home under the care of a licensed veterinarian.
*
Submit
Should be Empty: