Compassionate Veterinary Hospice Registration

Date

Month Day Year

Pet Owner's Name *

First Name Last Name

Co-owner, if applicable

First Name Last Name

Address *

Street Address

Street Address Line 2

City

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

Is this number:

E-mail

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

How did you hear about us *

If applicable, name of refering Veterinary Clinic or veterinarian

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

* Your Virtual Consultation will be recorded and stored as part of your pet's medical record. You'll also receive your own copy of the recorded consultation. If you don't wish to have the consultation recorded, please tell a member of our staff.

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

Month Day Year

*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

Would you like us to contact your primary care veterinarian with a report of our consultation? *

Yes, Please No Thank You

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?

Please answer the following questions to the best of your ability.

In the fields provided below, please answer for each of these - Have you, or has anyone in your house, or has anyone you've recently come into contact with:

Traveled outside of chicago? *

Recently had any cold or flu-like symptoms, including cough, fever, shortness of breath, stomach pain, loss of taste or sense of smell? *

Been tested for, or suspected of having Covid-19? *

Have an immune-compromising heath condition? *

Please briefly describe in what way your household has been social-distancing. (i.e, do you go to work, do you take public transit, how many public spaces have you visited in the last 7 days, etc) *

We at Compassionate Veterinary Hospice are doing our best to ensure the health and safety of your family, our staff, and every other family we will visit after being in your home. We appreciate your cooperation filling out this questionaire.

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

Yes No

Payment Method *

I would like to securely enter my credit card number now. *Payment for services will not be collected until after the appointment. I will call to provide you with my Care Credit number before my appointment.

You can safely enter your credit card number here. Your card will be processed for a fee of $0.25 in order to securely store your information. No other charges will occur until after your appointment. You may request estimates and itemized invoices at any time. You reserve the option to use a different payment method. There are no fees for cancellations or rescheduled appointments.

Credit Card Processing Fee $ 0.25

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

Household Symptom and Exposure Report

Payment