Pathway Consultation Intake Form

Pathway Consultation Intake Form

Thank you for choosing Greenwood Veterinary House Call Services for your pet’s Pathway Consultation. This virtual (video/telephone) consultation is designed to explore tailored options for your senior or terminally ill pet’s comfort and well-being, addressing their unique needs and your family’s goals. Please complete this form to help us understand your pet’s situation and ensure we can provide the best possible care. If you have questions about our fees or policies, you can find additional information on our website.
Consent to Telemedicine and Collection of Personal Information

Please read and sign/check below to consent to treatment for your pet.
I, the undersigned, consent to participate in a telemedicine consultation with Greenwood Veterinary House Call Services for my pet. I acknowledge and understand the following: Telemedicine consultations have limitations, as they do not allow for a hands-on physical examination of my pet. Consequently, they cannot replace an in-hospital examination or diagnostics that may be necessary for a comprehensive assessment. Medications may be prescribed based on the information provided during the consultation; however, controlled substances or long-term medications cannot be prescribed through telemedicine consultations. Recommendations made during the consultation are based on the information provided by me, and it is my responsibility to ensure that this information is complete and accurate to the best of my ability. In addition, I consent to the collection and use of my personal information in accordance with Greenwood Veterinary House Call Services' privacy policy, which complies with the requirements of the Personal Information and Electronic Documents Act. This information will be used to: Send email communications to you regarding your pet's care Maintain accurate client and patient records. Provide goods and services, including scheduling appointments, follow-ups, and billing. Communicate with third parties involved in my pet's care, such as other veterinary facilities or insurance providers, as necessary. This information will not be used or disclosed for purposes other than those for which it was collected, except with my consent or where required by law. By signing below, I confirm that I have read and understand this consent form, and I agree to the terms outlined above.

If your device does not permit on-screen signing, please proceed to the check box below.
Please check the box below to confirm your consent to the above. :*

I consent
Today's Date*

MonthDayYear
Date
Your Information
Your Full Name*

First NameLast Name
Your Email Address*
example@example.com
Your Home Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Your Preferred Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
How You Would Prefer We Contact You
While we strive to honor your preferred method of communication, there may be times when we reach out using an alternative method to ensure timely and effective communication.
Your Pet's Information
Pet's Name*
Pet's Gender*
Pet's Species*
Pet's Breed*
Pet's Age or Birthdate*
Pet's Colour*
Pet's Weight (please specify lbs or kg)*
If you are not sure, please provide your best estimate
Your Pet's Health History
If your pet has a regular veterinarian or has been seen by a veterinarian at another practice, please provide the practice(s) name here:
Has your pet been seen by another veterinarian (either your regular veterinarian or an emergency veterinary practice) for the issues you are most concerned about today?*

YesNo
If your pet has been diagnosed by another veterinarian, please provide the diagnosis here. If they have not been diagnosed, please provide a brief description of the signs/symptoms that you are seeing at home that are concerning you. *
Please check any symptoms or issues your pet is currently experiencing*

Pain/discomfortDifficulty walking/mobility issuesChanges in appetiteNausea or vomitingDifficulty breathingIncontinence or accidents in the houseDiarrheaConfusion or disorientationLethargy or decreased activityAnxiety or restlessnessCoughingSeizuresBleeding or oozing mass(es)Other
Please describe any additional medical concerns or issues with your pet that you would like to address during the appointment.
Reason for Requesting an Appointment
Please indicate the main reasons for requesting an appointment*

General palliative care guidancePain managementSymptom control (e.g., nausea, appetite, mobility)Exploring alternative therapies (e.g., supplements, herbal, cannabis)Quality-of-life assessmentEnd-of-life planning & supportOther
Your Goals and Concerns
What concerns you most about your pet's current condition or care needs?*
How are you managing your own feelings about your pet's care and well-being?

I am managing well and feel confident.I am managing but feel some challenges.I am finding it difficult to cope and would appreciate guidance.
What would you most like us to help you with during this consultation?
Please rate your level of concern about the following

(0 = no concern, 5 = very concerned):
My pet's comfort and pain levels:*
0 = no concern 5 = very concerned
Recognizing when it is time to make difficult decisions:*
0 = I'm confident I'll know when 5 = I'm worried I won't know when
My ability to manage nursing care:*
0 = I have no concerns about care 5 = I'm very concerned my ability
The impact on other family members (including children or other pets):*
0 = I have no worries 5 = I'm very worried about others
Coping with my own grief or emotional challenges:*
0 = I'll be sad, but I'll cope 5 = I'm worried about how I'll manage
Please list any treatment or therapies your pet is receiving or has recently received:*
Are there any treatments you are considering or would like to explore? If yes, please specify:
Are there any environmental challenges (e.g., stairs, slippery floors) that affect your pet's comfort or mobility? If yes, please describe:
Please describe your pet’s current diet, including: What type of food they eat (kibble, canned, home-cooked, raw, etc.), the brand(s) of food you use, how much you feed per meal and how often you feed each day.
Are there any additional concerns or information you'd like us to know?

Pathway Consultation Intake Form

Consent to Telemedicine and Collection of Personal Information

Your Information

Your Pet's Information

Your Pet's Health History

Reason for Requesting an Appointment

Your Goals and Concerns

Please rate your level of concern about the following

Thank You for Your Interest in Greenwood Veterinary House Call Services