Compassionate Veterinary Hospice Registration

Date

MonthDayYear

Pet Owner's Name*

First NameLast Name

Co-owner, if applicable

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number*

Area CodePhone Number

Is this number:

E-mail

We communicate primarily through email; please let us know your preferred method of contacting you:*

PhoneEmail

Do we have permission to text you with scheduling and prescription updates (i.e. time to schedule appointment; your prescription is ready, etc.)? By checking yes you agree to receive recurring messages from Aagly Duckling Veterinary Services DBA Compassionate Veterinary Hospice, Reply STOP to Opt out. Reply HELP for help. Message frequency varies. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages.*

YesNo

Please name other Family Members or other Pets that may be present for the appointment

How is parking near your home? (e.g. metered parking, garage, driveway, etc.) Please leave any parking information here.*

How did you hear about us*

If applicable, please tell us who referred you!*

What is your pet's Name?*

Please select your pet's species?*

What breed is your pet?*

What color is your pet?

How old is your pet?*

Gender*

How much does your pet approximately weigh?*

Please indicate what appointment are you requesting

If you have already scheduled an appointment please enter the date/time that was arranged:

MonthDayYear

* Your Virtual Consultation will be recorded and stored as part of your pet's medical record. You may also receive your own copy of the recorded consultation if you wish. If you do not wish to be recorded, please tell the DVM or Nurse at the time of appointment.*

I understand

Travel Charge - I understand that I may incur a travel charge due to scheduling an appointment during high traffic times or far distances. I understand that I can ask for an estimate prior to the appointment and one will be provided to me.*

I understand

*FILLING OUT THIS FORM DOES NOT SCHEDULE AN APPOINTMENT. If you have not yet scheduled an appointment time, please call or email our office to make those arrangements.*

Name of your primary care veterinarian?

Name of your primary care veterinary clinic?*

Name and Phone number

Does your pet have a history of fear/anxiety at the Vet's office, or do they typically need anti-anxiety meds for vet visits?*

What medication is your pet currently taking? (It's helpful to include doses and times of day, if possible).

What diagnoses have been made, or what are your major concerns at this time?

If this is a euthanasia appointment, what type of Aftercare would you prefer?

Any additional notes or comments?

I acknowledge that I have understood these questions and have answered correctly to the best of my ability.*

YesNo

Payment Method*

I understand that a credit card is necessary to reserve my appointment.

Please enter a payment method below. Your card will be run for a security deposit of $295, which will count toward any charges incurred.

Payment is due upon completion of service, consultation, or appointment.

Making this deposit will save your card on file for future services. You may change your form of payment at any time.

Detailed invoices, estimates, and prices of services are available upon request.

No fees or charges will result from rescheduling or cancelling a service or consultation.

CARE CREDIT

If you wish to use a Care Credit Card, you will need to call and give the number over the phone. You must still enter a valild credit card number below; the amount can either be credited to your account, or refunded once the deposit has been run on your Care Credit account.

My Products

Credit Card Processing$295.00

This will deposit a credit to your account with Compassionate Veterinary Hospice for upcoming services. If you wish to pay for services by a different method, please contact our team after submission to provide other payment information and to have this charge voided or refunded.

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please verify that you are human*

Compassionate Veterinary Hospice Registration

Client Information

Pet Information

Appointment Information

Payment