Client Registration

Client Registration

We recognize how challenging and emotional it is to make decisions to help your pet as their quality of life declines. By filling out this form, you will give us the information we need to provide care, support and guidance through this difficult time.
First we want to know what is happening with your pet's health.
Tell us more about what is happening with your pet right now. Please list any known medical conditions, and describe the symptoms that your pet is currently experiencing.*
Next we need some background information about your pet.
What is your pet's name?*
Is your pet a dog, a cat, or a rabbit?*

DogCatRabbit
What is your pet's breed?*
Examples: Labrador Retriever, Domestic Shorthair
What color is your pet?*
What is your pet's age?*
What is your pet's weight?*
Please include either kg or lb
Is your pet male or female?*

MaleFemale
Is your pet neutered or spayed?*

Neutered/SpayedIntact
How does your pet do with visits to the vet and getting needles? Do strangers in the home make your pet nervous? Do they ever get medication to help manage anxiety in these situations? We ask without judgement so we can give your pet the support they need for a calm and peaceful experience.*
To make sure we have complete medical records, it helps to know your pets regular veterinary clinic. Please list the clinic name below.*
If you have pet insurance please list the name of your provider. If not, you can leave this question blank.
Now we need some information about you.
What is your name?*

First NameLast Name
Please provide your preferred phone number.*
Format: (000) 000-0000.
If you have a secondary phone, you can list it here.
Please enter a valid phone number.Format: (000) 000-0000.
What is your email?*
What is your home address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Next we have some questions about your pet's family.
If your pet has a second owner, please provide their name.

First NameLast Name
What is the second owner's relationship to you?
Please provide their phone number.
Please provide their email.
Are there any additional family members or friends who may be present for your pet's appointment? Please list their names and their relationship to you. For any children, please include their ages.
Example: Emma Smith (daughter 15)
Do you share your home with any additional pets? Please list their names and species.
Example: Luna (dog)
As a mobile service, we have a couple of questions to make sure we can access your home.
Is there parking available for the veterinarian at your address?*

DrivewayVisitor ParkingStreet Parking
Is there any additional information that could help the veterinarian gain access to your home? (For example, a buzz number, a side door, or a hidden driveway.)
Finally, tell us how we can tailor our care to best fit your needs.
What service are you looking for to help your pet?*

In-Home EuthanasiaQuality of Life Assesment
If euthanasia is the most compassionate choice for your pet, what are your wishes for their aftercare?*

Private Cremation with Ashes ReturnedCommunal Cremation with No Ashes ReturnedHome BurialI am not sure yet.
Does your pet require an urgent same day appointment?*

YesNo
How would you prefer we get in touch with you?*

PhoneEmailPlease don't contact me at this time, I will reach out when I am ready.
If you have any other information, questions or concerns for us, please share them here.
If you would like, please feel free to include a picture of your pet. We love getting to know our patients.

Cancelof
Should be Empty:

Client Registration

First we want to know what is happening with your pet's health.

Next we need some background information about your pet.

Now we need some information about you.

Next we have some questions about your pet's family.

As a mobile service, we have a couple of questions to make sure we can access your home.

Finally, tell us how we can tailor our care to best fit your needs.