Family Information and Consent Form

Family Information and Consent Form
Welcome to Hope Veterinary Oncology Services. We are grateful for the oportunity to help you and your loved one. To help you get answers and formulate a plan in the most efficient way, we perform our consultations virtually or via phone call every Sunday.

Please complete this form at least 48 hours before your scheduled consultation. As a reminder, there is a $95 cancelation fee for appointments canceled within less than 24 hour notice.

Thank you,

Hope Veterinary Oncology Services

253-341-5835

info@hopeoncology.vet
Owner Information
Owner Name:

First NameLast Name
Preferred Pronouns:
Co-owner Name

First NameLast Name
Preferred Pronouns:
Mobile Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Co-owner Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Preferred Form of Contact
Does Hope Veterinary have permission to contact you using any of the following methods (select all the apply):
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Information
Pet's Name:
Species:
Breed:
Color:
Gender:
Date of Birth

MonthDayYear
Date
Do you have insurance for your pet? If yes, please list the name of the insurance company.
What type of cancer does your pet have? If your pet has been diagnosed with Lymphoma, please call us at 253-341-5835 to schedule.
Please list any veterinary clinics that your pet has visited in the last year; IF LISTING MULTIPLE HOSPITALS, PLEASE INDICATE WHICH HOSPITAL DIAGNOSED THE CANCER:
Please list any medications and supplements that your pet is currently on. Please include strength and frequency of dosing:
What diet is your pet currently on?
Does your pet have any other significant medical conditions?
Does your pet have any known allergies?
What are your pet's favorite activities?
How would you describe your pet around other animals and people?
Does your pet have any sensitive areas that they do not like having touched by you or others (feet,ears)?
Are there procedures that your pet does not like having performed at a veterinary facility(nail trims, blood draw, temperature)?
What are your pet’s favorite treats (please bring some to their next visit to our facility)? What are your pet’s favorite toys (if any)?
Has your pet ever needed any prescribed medications or supplements to help with a visit to a veterinary hospital? If so, what were they?
Is there anything else you would like us to know about your pet?

Are there any cultural or religious beliefs that you would like us to be aware of that could impact the medical decisions for your pet while under our care? (Please note, this can be discussed in person if preferred and is not required to be answered)
RESPECT FOR STAFF: Our staff works diligently to provide you and your pet with the best care and service. While we understand that having a pet with a cancer diagnosis can be challenging, abusive or inappropriate behavior toward staff will not be tolerated. Any mistreatment of staff will result in the immediate dismissal from the clinic.

LATE ARRIVALS/NO SHOW: If you arrive late, we will do our best to accommodate you within your remaining appointment time. However, if the delay significantly impacts the other patient appointments, you may be asked to reschedule and pay the late/no-show fee. Appointment arrivals over 10 minutes past the scheduled start time may result in the no-show/late fee of $95.
MEDIA CONSENT: Does Hope Veterinary have permission to take photographs of you pet, and to copyright, use or publish the same in print and/or electronically
TREATMENT AND FINANCIAL CONSENT: By typing my name below, I do hereby, certify that I am the owner, or am assuming responsibility, financial, or otherwise, for the pet being presented. I understand that I assume any and all risks. I hereby authorize the doctor to examine, prescribe, and/or treat the pet described on this form. I assume full responsibility for all the charges incurred for the care of the pet. I understand that all charges are due at the time of the service. I acknowledge that there is a 3 % service fee applied to all credit card transactions; this fee does not apply to debit cards, HSA cards, bank-issued gift cards that function as prepaid debit cards. The service fee does not exceed the actual processing costs charged to Hope for accepting credit cards and is charged only when a credit card is used.

First NameLast Name
Today's Date:

MonthDayYear
Date
Please attach your favorite picture of you pet that we can add to their profile.

Cancelof
Should be Empty:

Family Information and Consent Form

Owner Information

Patient Information