Housecall Nursing Care Service Appointment Form 上門護理服務預約表格
請填寫此表格，以幫助我們更快地了解您的寵物 Please fill out this form to help us understand your pet better and more quickly.
主人姓名 Owner's Name:
*
名 First Name
姓 Last Name
聯絡電話 Phone Number:
*
Format: (000)00000000.
電子 E-mail:
example@example.com
地址 Address:
*
State / Province
Postal / Zip Code
寵物名字 Pet's Name:
*
寵物類型 Breed of Pet:
*
寵物年齡 Pet's Age:
*
寵物性別 Pet's Gender:
*
男 Male
女 Female
是否已絕育 Desexed?
*
是 Yes
否 No
家庭獸醫 Regular Vet:
*
預約原因 Reason for Appointment:
*
1. 血液採集 Blood Collection
2. 處理肛門腺 Express Anal Glands
3. 耳道沖洗和清潔 Ear Flushing And Cleaning
4. 餵藥 Medication Administration
5. 根據獸醫指示進行注射 Injection Administration as directed by Veterinarians
6. 皮下液體輸注(打皮下水) Subcutaneous Fluid Administration
7. 手術後傷口檢查 Post Surgery Wound Checks
8. 傷口處理 Wound Management
9. 血糖檢查 Blood Glucose Checks
10. 血壓檢查 Blood Pressure Checks
其他 Other
偏好的拜訪時間 Preferred Visiting Time:
*
閒日早上 Weekday Morning
閒日下午 Weekday Afternoon
週未早上 Weekend Morning
週未下午 Weekend Afternoon
只可以晚上時間 Only Nightime
給我們的訊息 Message for us.
你是如何得知我們的？How did you hear about us?
*
請選擇 Please Select
診所介紹 Clinic Referral
朋友介紹 From friend
Instagram
Other
*
* I have given my consent to share my personal information with Cozy Care for this purpose. 我已同意將我的個人資料分享給Cozy Care用於此用途。
* I will request my regular vet to send the medical history to info@cozycare-hk.com. 我會聯絡我的獸醫診所將醫療病歷發送至 info@cozycare-hk.com
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