Appointment form for a Comfort Care, Quality of Life, Acupuncture
Thank you for your interest in our in-home Comfort Care, Quality of Life, and Acupuncture services. These visits are designed to support pets with chronic illness, mobility concerns, pain management needs, or age-related changes in the comfort of their home.This form helps our veterinarian prepare for your visit by gathering important information about your pet’s condition and goals for care. Please complete the form as thoroughly as possible. Once submitted, our team will review your responses and follow up with next steps to finalize your appointment.
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
*
Please briefly describe why you are seeking care at this time (e.g., pain management, mobility concerns, chronic illness support, quality of life assessment, acupuncture):
*
Please list your pet’s primary veterinary hospital and/or veterinarian, including any specialists currently involved in their care.
*
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: