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
*
-
Month
-
Day
Year
Date
Your Information
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Home Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Your Preferred Phone Number
*
Please enter a valid phone number.
How You Would Prefer We Contact You
Phone
Email
Either Phone or Email
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
*
Please Select
MN Male - Neutered
FS Female - Spayed
M Male - Not neutered
F Female - Not spayed
Pet's Species
*
Please Select
Dog
Cat
Other
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:
Please Select
A.E.C. Of Durham Region
Ajax Animal Hospital
Ajax West Veterinary Hospital
Amberlea Animal Hospital
Anderson Veterinary Clinic
Animal Clinic Of Brooklin
Animal Hospital Of Bowmanville
Aspen Springs Animal Hospital
Baker Animal Clinic
Baldwin Animal Hospital
Bellamy-Lawrence Animal Hospital
Bowmanville Veterinary Clinic
Brealey Drive Animal Clinic
Brelmar Veterinary Clinic
Bridle Trail Veterinary
Brock Street Animal Hospital
Brooklin Veterinary Hospital
Callbeck Animal Hospital
Cambray Veterinary Services
Carter Veterinary Hospital
Cavan Hills Veterinary Services
Cedarbrae Veterinary Clinic
Claremont Veterinary Services
Clarington Animal Hospital
Courtice Pet Clinic
Dale Veterinary Clinic
Dr. Sarah Silcox
Durham Veterinary Clinic (Bowmanville)
East Oshawa Animal Hospital
Forestbrook Pet Hospital
Ganaraska Animal Clinic
Grandview Bloor Animal Clinic
Guildcrest Cat Hospital
Harmony Road Animal Hospital
Harwood Pet Hospital
Herongate Animal Hospital
Highway 2 Vet Office
Kawartha Animal Hospital
Kennedy Eglinton Animal Hospital
King Hopkins Pet Hospital
Mccowan Animal Clinic
Millennium City Veterinary Hospital
Morningstar Pet Hospital
Newcastle Veterinary Clinic
Omemee Veterinary Hospital
Orono Veterinary Hospital
Parkdale Animal Hospital (Toronto)
Pet Hospital On Main
Pickering Animal Hospital
Pickering Village Pet Hospital
Pine Ridge Veterinary Clinic
Port Perry Animal Hospital
Ritson Veterinary Clinic
Riverside Pet Hospital
Rosebank Animal Hospital
Rossland Animal Hospital
Rosswell Animal Hospital
Rouge Valley Veterinary Hospital
Salem Animal Hospital
Scugog Animal Hospital
Sheridan Veterinary Services
Simcoe Rossland Animal Hospital
Simcoe Street North Animal Hospital
South Whitby Veterinary Services
Southside Pet Clinic
Springwood Animal Hospital (& Housecall Services)
Taunton Road Animal Hospital
Thicketwood Veterinary Hospital
Thickson Road Pet Hospital Prof. Corp.
Uxbridge Veterinary Hospital
VCA Canada 404 Veterinary Emergency Hospital
VCA Canada Birchmount Veterinary Clinic
VCA Canada Mackay Animal Clinic
VCA Canada Morningside Pet Hospital
VCA Canada Oshawa Animal Hospital
Vets Around The Corner
West Hill Animal Clinic
Westney Road Animal Clinic
Whitby Animal Hospital
White Oaks Animal Hospital
Whites Road Animal Hospital
Wilson Road Veterinary Clinic
Woodbine Animal Service Ltd.
Other
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?
*
Yes
No
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/discomfort
Difficulty walking/mobility issues
Changes in appetite
Nausea or vomiting
Difficulty breathing
Incontinence or accidents in the house
Diarrhea
Confusion or disorientation
Lethargy or decreased activity
Anxiety or restlessness
Coughing
Seizures
Bleeding 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 guidance
Pain management
Symptom control (e.g., nausea, appetite, mobility)
Exploring alternative therapies (e.g., supplements, herbal, cannabis)
Quality-of-life assessment
End-of-life planning & support
Other
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?
Print
Save
Submit
Back
Next
Save
Thank You for Your Interest in Greenwood Veterinary House Call Services
We appreciate you considering Greenwood Veterinary House Call Services for your pet's care. Unfortunately, without your consent to collect and use your personal information, we are unable to proceed with creating a medical file for your pet or scheduling an appointment.If you have any questions or would like to discuss this further, please don't hesitate to reach out to us directly at 289-987-7297 or via email at greenwoodvethospice@gmail.com.Thank you for understanding, and we wish you and your pet all the best.
Should be Empty: