Crossroads Consultation Intake Form

Crossroads Consultation Intake Form

Thank you for choosing Greenwood Veterinary House Call Services for your Crossroads Consultation. This consultation is designed to evaluate your pet’s well-being, provide clarity about their current condition, and guide you in making informed decisions for their care. Please take a few moments to complete this form to help us better understand your pet’s needs and your goals. Together, we will navigate this journey with compassion and expertise.
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.

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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.
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 (yrs)*
If you are not sure, please provide your best estimate
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 issue(s) 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. *
In your own words, what is your understanding of your pet's current condition and prognosis?*
What treatments, therapies, or medications is your pet currently receiving?*
Family's Goals and Concerns
What are your goals for your pet's care at this stage?
What are your greatest concerns about your pet's current condition?
What would you most like us to help you with during this consultation?
Quality-of-Life (QOL) Questions

Please rate the following aspects of your pet's quality of life on a scale of 1 to 5 (1 = Very Poor, 5 = Excellent)
Pain or discomfort management: How well is your pet's pain or discomfort controlled?
0=Severe, uncontrolled pain; 5= Pain-free and comfortable
Mobility: How easily can your pet move to perform basic activities (e.g., getting up and down, walking, eliminating)
0=Unable to move; 5=Moves with ease and no difficulty
Appetite and ability to eat: Is your pet eating as much as they need to maintain their health?
0=Not eating at all; 5=Eating well with a good appetite
Hydration: Is your pet drinking enough water to stay hydrated, without vomiting or diarrhea?
0=Severely dehydrated; 5=Well-hydrated and drinking normally
Breathing: Is your pet breathing comfortably and without effort?
0=Laboured, noisy, or distressed breathing; 5=Breathing is calm and effortless
Energy levels: Does your pet have enough energy to engage in daily activities?
0=Always lethargic; 5=Energetic and alert
Ability to rest and sleep: Is your pet able to rest and sleep without difficulty?
0=Restless or unable to sleep; 5=Sleeps well and peacefully
Emotional state: Does your pet seem calm and content?
0=Always anxious, restless, or withdrawn; 5=Relaxed, content, and happy
Interaction with family: Is your pet engaging with you, other pets, or family members?
0=Completely withdrawn; 5=Engaging and affectionate as usual
Toileting habits: Is your pet able to urinate and defecate without difficulty or accidents?
0=Incontinent or struggling significantly; 5=Toilets normally without issues
Enjoyment of favourite activies: Does your pet still enjoy their favourite activities (e.g., toys, food, being outdoors)?
0=No longer interested in any activities; 5=Fully engaged and enjoying favourite activities
Ability to groom or maintain cleanliness: Can your pet keep themselves clean and comfortable?
0=Unable to groom and often soiled; 5=Clean and well-groomed without assistance
Responsiveness to medical treatments: Is your pet responding well to their current treatments?
0=No improvement or worsening condition; 5=Fully responsive and improving
Ease of caregiving: How manageable is your pet's care for you and your family?
0=Overwhelming and unmanageable; 5=Easily manageable
Changes in condition: Have there been significant changes in your pet's condition recently?
0=Rapid and concerning decline; 5=Stable with no concerning changes
Are there specific changes in your pet's behaviour or health that you've noticed recently?
What do you believe is most important for your pet's quality of life?
Caregiver's Well-being
How are you manageing your pet's care emotionally and physically? (0 = poorly/struggling, 5 = okay)
Have you experienced a similar situation with another pet before? If so, what aspects were most difficult or comforting for you?
Do you feel confident in recognizing signs that your pet's needs may be changing?

YesNoNot sure
End-of-Life Planning (Optional)

We understand this topic is difficult, but planning ahead can help provide peace of mind.
Would you like guidance on how to prepare for your pet's end-of-life care?

YesNo
Are there specific wishes you have for your pet's passing (e.g., in-home euthanasia, memorial options)?
Final Notes
Is there anything else you would like us to know about your pet or your family's needs?

Crossroads Consultation Intake Form

Consent to Telemedicine and Collection of Personal Information

Your Information

Your Pet's Information

Your Pet's Health History

Family's Goals and Concerns

Quality-of-Life (QOL) Questions

Caregiver's Well-being

End-of-Life Planning (Optional)

Final Notes