Appointment Request Form

Appointment Request Form

Answer the questions below to help us schedule your visit.
Client Information

Help us get to know you
Owner Name

First NameLast Name
Owner Phone
Please enter a valid phone number.Format: (000) 000-0000.
Owner Email
example@example.com
Owner Pronouns
What is the best way to contact you to schedule this appointment?
Does your pet have a Co-Owner?
Co-Owner Name

First NameLast Name
Co-owner Phone
Please enter a valid phone number.Format: (000) 000-0000.
Co-owner Email
example@example.com
Co-owner Pronouns
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Pet Information

Help us get to know your pet(s)
How many pets do you have?
Pet Information
Does your pet(s) take medications or supplements?
Medications & Supplements given to your pet(s)
Appointment Request Details
What is this appointment for?
Primary Concern
Doctor Preference
What was your previous veterinary clinic?
Vet and/or Clinic Name
Date last seen by your previous veterinary clinic (approximate month/year is fine)
Month/Year
Is the location/address for your in-home visit the same as your address listed above?
Location / address for the visit

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
What is your preferred time of day for your appointment?
Please select morning, afternoon, or no preference.
What type of residence will the appointment take place at?

Other
Any special considerations for entering the home? (e.g. parking instructions, gate access, pet reactivity upon entry. If nothing of note, please type N/A)
Eating Habits: Have you noticed the following?

Other
Drinking Habits: Have you noticed the following?

Other
Bathroom Habits: Please select all the apply

Other
Is your pet experiencing new, changing, or uncomfortable masses?
If yes, please describe
Mobility: Please select all the apply

Other
Cat Owners: Please select all that apply (if none apply, please leave blank)

Other
Does your pet go to boarding, daycare, dog parks, or the groomer's?
Does the pet experience anxiety at veterinary visits?
If yes, please describe your pet's behavior at veterinary visits
Is medication given to help with anxiety at veterinary visits?
Anxiety Medications given to the pet
Does your pet experience anxiety when visitors come to the home?
Additional concerns or notes
Anything else we should know before scheduling?
Deposit Acknowledgment & Media Consent
Deposit Acknowledgement: I acknowledge that to schedule an appointment, I must place a deposit of $150. I understand that this deposit will cover the house call fee. If an appointment is cancelled with at least 48 hours advance notice, the deposit will be refunded in full. I understand that if I cancel my appointment within 48 hours of its scheduled time, or if my pet cannot be found or handled at the time of the appointment, my deposit will be forfeited.
Media consent: I consent to have my pet's name and image used for social media purposes.
AI Consent: We may use medical scribe software that employs artificial intelligence to help write our records efficiently and thoroughly. Do you consent to this use?
How did you hear about us?
Should be Empty:

Appointment Request Form

Client Information

Pet Information

Appointment Request Details

Deposit Acknowledgment & Media Consent