Clone of Appointment Request Form

Appointment Request: In-Home Quality-of-Life Consultation

When a beloved pet begins experiencing changes related to aging, chronic illness, or declining health, knowing how best to support them can feel overwhelming.House Call Vet RVA offers compassionate, in-home quality-of-life consultations to help families better understand their pet's comfort, daily well-being, and care options.Please complete the form below so Dr. Hemsley can learn more about your pet and your family's concerns.
Name

PrefixFirst NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Can you receive text messages at this number?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet’s Name
Approximate Age
Species
Pet’s Weight (in pounds)
Patient’s Weight (in pounds)
Who is your pet’s current veterinarian?
Primary Veterinary Clinic
Your Pet's Current Quality of Life
What prompted you to request a quality-of-life consultation? Select all that apply.

Other
What changes have you noticed in your pet? Select all that apply.
Does your pet have any diagnosed medical conditions?
Does your pet have any diagnosed medical conditions?
Is your pet currently receiving medications or treatments?
How would you describe your pet's overall comfort right now?
What concerns you most about your pet's quality of life?
How Can We Best Support You?
When would you ideally like to schedule?
Preferred days or times (optional)
Anything else you would like us to know? (optional)
Before Submitting Your Request
Consultation Fee

In-home quality-of-life consultations begin at $400, with an additional travel fee based on your location. Any applicable fees will be communicated before your appointment is confirmed.

Important: Submitting this form is an appointment request and does not guarantee availability or confirm an appointment. Our team will contact you regarding scheduling and next steps.

If your pet is experiencing severe difficulty breathing, collapse, uncontrolled seizures, or other immediate distress, please contact an emergency veterinary hospital. This form is not monitored continuously.
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Appointment Request: In-Home Quality-of-Life Consultation

Your Pet's Current Quality of Life