Greenleaf Consultation Intake Form
Thank you for choosing Greenwood Veterinary House Call Services to explore the potential benefits of cannabis therapy for your pet. This form helps us gather important details about your pet's health and needs, so we can provide personalized guidance and support. Please complete the form to the best of your ability before your consultation.
Consent
Prior to our consultation it is important to understand the legal status of cannabis in Canada in regards to the treatment of animals. Please read the following carefully.
Although cannabis can be legally purchased by any Canadian adult, there are currently no cannabis products available that are approved for use in animals. Veterinarians are not legally permitted to prescribe, dispense, or administer cannabis to our patients. We can, however, provide guidance and recommendations for specific products that can be purchased legally through provincially licensed cannabis retailers. These products are intended for human use, and while they are required to undergo a level of testing for content and purity, there remains the possibility of significant variability between products and batches. Our consultations are intended to allow us an opportunity to better understand your pet's indivdual needs, the role that cannabis may play in their condition, to review and discuss any possible risks or drug interactions, and then recommend one or more products that would be most suitable, along wtih guidance on dosing, monitoring, and follow-up.
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I understand the purpose and limitations of a cannabis consultation and would like to proceed.
Greenwood Veterinary House Call Services has a personal information policy in accordance with the requirements of the Personal Information and Electronic Documents Act. This information is used to maintain complete and accurate client files; provide goods and services to veterinary clients, including contacting clients to schedule appointments and follow-up on patient treatment, billing for goods and services and notifying clients about new services and promotional offers; and communicating and working with third parties providing veterinary medical or other services to clients, including other veterinary facilities and insurance companies which may pay for all or part of the cost of such services. This information will not be used or disclosed for purposes other than those for which it was collected, except with my consent, or except where use of disclosure is required by law.
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Yes, I consent to the collection and use of my personal information for maintaining my pet's medical record.
I'm interested in cannabis for my pet because (check all that apply):
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My regular veterinarian recommended that I speak with you.
I have heard it may be helpful for my pet's condition.
I, or someone close to me, has found relief using medical cannabis and I think it may also help my pet.
I would prefer a more 'natural' treatment for my pet.
Conventional therapy is not helping my pet, or is no longer tolerated by my pet.
Other
My experience and knowledge regarding cannabis can be best descrbied by which of the following?
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I have no experience or knowledge of cannabis, but am hoping it may help my pet.
I have some experience and/or knowledge of cannabis, but not in regards to its medical use.
I have some experience and/or knowledge of the medical use of cannabis, but am looking for guidance to ensure the most appropriate treatment for my pet.
I am very knowledgeable about medical cannabis for people, but am looking for guidance to ensure the most appropriate treatment for my pet.
Your Information
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
Province
Postal Code
Preferred Phone Number
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Please enter a valid phone number.
Email
*
This email will be used to send follow-up communications and is part of your pet's medical record. It will not be shared with anyone outside of your pet's care team. Providing your email here serves as consent for us to use it to contact you.
How You Would Prefer We Contact You
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Please Select
Phone
Email
Either Phone or Email
While we strive to honour 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
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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
*
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 Medical Information
Who is your pet's primary care veterinarian/veterinary practice?
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For what condition are you requesting a cannabis consultation (one or more conditions may be listed)
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Does your pet currently have any other conditions, or a history of any other health issues? Please describe.
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Please list all of your pet's current treatments including all medications and supplements.
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Please describe your pet's diet.
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Please include the type of food (such as dry, canned, home-cooked, commercial raw, etc.), as well as the amount fed and feeding schedule.
Insurance Coverage
If you have pet insurance, please provide the name of your insurance company and your pet's policy number if you would like us to complete an insurance claim form following your consultation.
Submit
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