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Blogs

Pet First Aid-Tips Every Pet Owner Should Know

Our pets are practically part of our family and we want to care for them accordingly. But would you know how to react if your pet experienced a medical emergency?…

Jason Parks In Blogs

New Year’s Resolution: Walk Your Dog Challenge!

The Near Year is almost upon us. While many take this time to rest and celebrate the holidays, many others also like to establish goals for themselves in the New…

Dug The Dog In Blogs

How Often Does My Dog or Cat Need to See the Vet?

Our pets enrich our lives, providing companionship and support when we need it most. It’s only natural, then, that we want to give our pets a happy, healthy life in…

Dug The Dog In Blogs

A note from Dug the Dog | Happy Holidays YVV Family!!!

We’re already well into December, and it is officially the holiday season! I get so excited for this time of year. The holiday season always seems to lift my spirits...

Dug The Dog In Blogs

Dug Unleashed | Thanksgiving Blog

Happy Fall Y’all! Dug the Dog here. The season has arrived, and we have officially made it to November. Now is the time to start preparing for the family gatherings...

Dug The Dog In Blogs

Dug Unleashed: Dug’s Favorite Halloween Costumes For Cats

Thank you so much for taking the time to read Dug Unleashed. You know the saying, Dogs are a man’s best friend and our mascot, Dug, loves to share fun...

Dug The Dog In Blogs

Dug Unleashed: Dug’s Favorite Halloween Costumes For Dogs

Thank you so much for taking the time to read Dug Unleashed. You know the saying, Dogs are a man's best friend and our mascot, Dug, loves to share fun pet...

Dug The Dog In Blogs

Introduction

Hi friends! My name is Dug and my friends and I work for a wonderful mobile veterinary team called Your Visiting Veterinarian. We are a mobile vet team that provides...

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740-899-5789

I, *

First

Last

living at 107 Blakemore Drive, Delaware, OH 43015, agree to the following:

I attest that I am the owner of Henley Siegle-Phillips, a black and tan German Shepherd canine.

I have elected to have the initial bandage application and subsequent care completed over telehealth with Your Visiting Veterinarian (YVV) and YVV has agreed to do so. In-person appointments and a referral to a brick-and-mortar animal clinic were advised and I have declined both.

Rechecks via video call, phone call, or email will be advised based on YVV's veterinarian’s medical judgment of what is in Henley’s best interest. I agree to follow the schedule that YVV's veterinarian will determine and I agree to reply to all communication promptly. YVV has agreed in kind.

All remote consult time (research, email communication, or phone communication) related to Henley will be billed daily at $180 per hour in 20-minute increments. Any previous balance must be paid in full before additional services are rendered. This can be done via credit card over the phone by calling YVV's business phone number: 740-899-5789.

Pricing is as followings:
- 1-20 minutes: $60
- 21-40 minutes: $120
- 41-60 minutes: $180
- 61-80 minutes: $240
- Etc.

Telemedicine appointments done via video call will be up to 30 minutes and cost $95. Any additional time over the 30 minutes will be billed at the rate mentioned previously. YVV's telemedicine consent form must be signed prior to my initial telemedicine appointment and can be found under the “Contact Us” tab of YVV's website or on the previous page.

Since the MicroLyte bandages are being specially ordered for Henley, I will pay for them prior to them being ordered and I understand that there will be no refund available. In addition, I will be billed $60 to mail the samples, which includes the costs required to prepare and transport samples to the carrier and the shipping cost.

YVV will give me advance notice should any fee increases be required due to the increasing cost of goods or services.

An in-person exam must be completed every twelve months to continue remote care. Henley’s last in-person appointment was January 23rd, 2023.

While we certainly hope for a very successful outcome for Henley, I understand that remote care of Henley does not guarantee a successful outcome, even if all instructions are followed. If YVV determines unsatisfactory improvement of Henley’s condition(s) or inadequate compliance, YVV may warrant a change to this agreement. One such change may be the requiring of in-person care or a referral to a brick-and-mortar clinic. If YVV and I cannot agree to the new terms, at that time YVV may elect to no longer provide care for Henley. At such point YVV will email Henley’s records to any veterinary clinic I wish.

I sign, indicating that I have read, understand and agree to the terms and conditions to manage Henley remotely.

Signature *

Contact Form

Name *

First

Middle

Last

First and Last are required.

Phone *

Email *

Address *

City *

State *

Zip Code *

Comment or Message

CONTACT FORM TEST POP

Name *

First

Middle

Last

First and Last are required.

Phone *

Email *

Address *

City *

State *

Zip Code *

Comment or Message

Consent to Telemedicine

Name *

First

Middle

Last

First and Last are required.

Pet's name *

Phone *

Email *

I agree: *

My veterinarian has offered me the option of a Telehealth Consult. Telehealth appointments are 30 minute appointments that can be done via a phone call or video call. I am undertaking this consultation with the understanding that there are limitations to what my veterinarian can deduce about my animal’s condition without a physical examination and/or other detailed investigations best done in person. To minimize the risks of errors of clinical judgement my veterinarian may recommend an in-person exam and/or further diagnostic tests. This will then be up to me to decide if I proceed. I understand that it is my responsibility to contact my veterinarian and/or bring the pet for an exam at the nearest emergency hospital if my pet’s condition persists or deteriorates unexpectedly. I understand that payment for my consultation and any medications recommended, agreed to and/or delivered to me will be completed in full on my nominated credit card at the end of this consultation. I understand that the cost of my Telehealth consultation does NOT include payment for other services, examples of which include but are not limited to such things as medications, supplements, tests, procedures, diagnostics, referrals to specialists, hospital care, etc. I understand that I am consulting with a veterinary professional employed at Your Visiting Veterinarian LLC who is a licensed Veterinary Practitioner in the state of Ohio. I also confirm that my details including my stated residence in the state of Ohio are correct.

Signature *

Telemedicine SOAP Notes

Doctor's Name *

Doctor's Email Address

If you would like a copy emailed to you, please fill this out.

Clinic Telehealth was for *

Clinic's Email *

Owner's Name *

Pet's Name *

Date / Time of Appointment *

Date

Time

SOAP Notes *

Attachments or Pictures

Click or drag files to this area to upload. You can upload up to 5 files.

Please feel free to upload any attachments or pictures that may be relevant.

New Acupuncture Form

Owner's Name *

First

Middle

Last

First and Last are required

Phone *

Email *

Pet's Name *

Pet's Specie *

Pet's breed *

Please briefly describe your pet's primary issue *

Is this primary concern acute or chronic? *

Acute
Chronic

Please briefly describe your pet's secondary issue, if they have one.

Is this secondary concern acute or chronic?

Acute
Chronic

Please briefly describe your pet's third issue, if they have one.

Is this third concern acute or chronic?

Acute
Chronic

Please briefly describe any additional issues that your pet has.

Are these additional issues acute, chronic or both?

Acute
Chronic
Both

How is your pet's appetite? *

Normal
Reduced
Ravenous

What type of food are you feeding your pet? *

Dry
Wet
Fresh
Raw
Other (please describe)

Check all that apply

Please describe your previous selection. (type of food)

What brand of food are you feeding your pet? *

Hills
Iams
Purina
Royal Canine
Other (please describe)

Please describe your previous answer. What is the name of the food and how much do you feed them? (brand of food)

What is the main ingredient/protein in the food? *

Chicken
Beef
Grain
Other (please describe)

Please describe your previous answer. (ingredient)

What supplements or medication is your pet currently on? *

Please give a brief overview of their previous or current medication(s). Please include dosage and frequency.

Please give a brief overview of their previous or current medical condition(s).

How is their stool? *

Firm
Soft
Diarrhea

What is their frequency? *

Once every few days
Once per day
Two to three times per day
More than three times per day

Is there gas or vomiting? *

Yes (please describe)
No

Please describe your previous answer. (gas or vomiting)

Do they cough? *

Yes (please describe)
No

Please describe your previous answer. (cough)

How is your pet's drinking? *

Normal
Reduced
Increased

How is their energy level? *

Normal
Reduced
Increased

Do they prefer cool or warm environments/surfaces? *

Yes (please describe)
No

Please describe your previous answer. (environment/surface)

Do they have any trouble falling or staying asleep? *

Yes (please describe)
No

Please describe your previous answer. (sleep)

What is their overall emotional state? *

Normal
Happier
Sadder
Other (please describe)

Please describe your previous answer. (emotion)

Has there been anything stressful going on in your pet's life?

Ex: changing homes, new pet, new family member, home renovations, etc

Does your pet have any lameness or stiffness? *

Yes (please describe)
No

Please describe your previous answer. (lameness)

Is your pet laid back/sweet when around humans or other animals? *

Is your pet confident/aloof when around humans or other animals? *

Is your pet timid/shy when around humans or other animals? *

Is your pet friendly/hyperactive/center of attention when around humans or other animals? *

Is your pet in charge/forceful/aggressive when around humans or other animals? *

Does your pet enjoy being touched or massaged? *

If you are a new client, please also fill out the New Client Form and the New Patient form after submitting this form. Thank you.

Influenza Vaccine Form

Name *

First

Middle

Last

First and Last are required.

Phone *

Do you have interest in your pet receiving an additional influenza vaccine? *

No thank you. Please do not contact me concerning this matter.
Yes. Please contact me to schedule an appointment for an influenza vaccine booster. Thank you.

Pet(s) Name(s) *

Decline Doctor's Advice

Name *

First

Middle

Last

First and Last are required.

Address *

City *

State

Zip Code *

Pet's Name *

Pet Species *

Breed

Service(s) that are being declined *

Owner's Consent *

I attest that I am the owner or authorized representative of the animal described above. The veterinarian has advised diagnostics, treatments, and/or other services for my pet and I have chosen to decline the items that are listed above. The doctor has explained to me the potential negative results of my decision and they have answered all of my questions. I understand what we have discussed.

Release of liability *

I release Your Visiting Veterinarian, it's staff, and anyone associated with Your Visiting Veterinarian from any liability, impact, or costs that my decision may result in now and into the future.

Signature *

New Client Form

Name *

First

Middle

Last

First and Last are required.

Phone *

Email *

Preferred method of contact *

Phone
Text
Email

Address *

City *

State *

Zip Code *

Is anyone else authorized to make medical decisions for your pet? *

Name of authorized person *

First

Last

Phone of authorized person *

Email of authorized person *

Address of authorized person *

City of authorized person *

State of authorized person *

Zip Code of authorized person *

Preferred method of contact for authorized person *

Phone
Text
Email

How did you find out about us? *

Personal Recommendation
Google
Another search engine (Bing, DuckDuckGo, Yahoo, etc)
Facebook
Another social media (Instagram, Nextdoor, LinkedIn, etc)
Print Ad
Other

Please explain how you found us.

Who may we thank for the recommendation?

Does any PERSON in your family have any food allergies?

I.E. peanut butter.

What allergens are they?

We will make sure to not give your pet any treats that contain the allergens you have listed above.

Photo and Video Consent

At Your Visiting Veterinarian LLC, we love sharing photos and videos of our happy clients and their adorable pets! Please select whether we have permission to use photos or video taken at your pet’s appointment on our website, social media, and for educational or marketing purposes.

Yes - I hereby grant full permission to Your Visiting Veterinarian LLC to use any photos or videos taken during our appointment including of pets and people and their names. This consent also serves to waive all rights of privacy or compensation which I may have in connection with the use of my photograph or video and/or my pet’s photograph or video.
No, thank you - please do not share any photos or videos taken at my appointment.

24-Hour Cancellation Policy

As a mobile practice, we are limited in the number of appointments we can see per day. Appointments canceled within 24 hours of the scheduled appointment time prevent us from being able to fill that appointment spot and disrupts the timing of our other appointments that day. In order to account for the financial hardship this places on our practice, we have a strict cancellation policy in place. Appointments canceled within 24 hours of the scheduled appointment time will be charged a cancellation fee in the amount of the sum of the examination fee(s) for the pet(s) whose appointment is (are) being canceled.

I agree to the 24-Hour Cancellation Policy

No-Show Policy

As a mobile practice, we are limited in the number of appointments we can see per day. If you are not home when we arrive for your pet's appointment, this prevents us from being able to fill that appointment spot and disrupts the timing of our other appointments that day. In order to account for the financial hardship this places on our practice, we have a strict no-show policy in place. If you are not home when we arrive for your pet's appointment you will be charged a no-show fee in the amount of the sum of the examination fee(s) for the pet(s) whose appointment is (are) being canceled plus the trip fee. *

I agree to the No-Show Policy

Signature *

Consent to Euthanasia

Name *

First

Middle

Last

First and Last are required.

Address *

City *

State *

Zip Code *

Pet's Name *

Pet Species *

Breed

After Care Preference

Owner will handle
Faithful Companion
Forever Friends

Owner's Consent *

I attest that I am the owner of the animal described above. I give the doctor and her assistants complete authority to euthanize this animal. I release the doctor and her assistants from any liability for euthanizing this animal.

Has not bitten nor rabies *

I also attest that this animal has not bitten any person or animal in the past 10 days and to the best of my ability has not been exposed to rabies.

Signature *

New Small Mammal Patient Form

Owner's Name *

First

Middle

Last

First and Last are required.

Phone *

Email *

Pet's name *

Pet Species *

Chinchilla
Gerbil
Guinea Pig
Hamster
Rabbit
Rat
Other

What species are they?

Breed

Color *

Pet's Gender *

Male
Female
I'm not sure

Is your pet spayed or neutered? *

Yes
No
I'm not sure

What is your pet's birthday or approximate age? *

Where did you get your pet? *

Reason for our mobile vet visit? *

What do you feed your pet? *

Please include the brand of pet food and include table scraps and treats if applicable.

How much food does your pet get fed? *

Does your pet spend any time outdoors? *

Does your pet have any cage mates or other pets in the home? *

Please Explain

Does your chinchilla take regular dust baths?

Yes
No
I'm not sure

Does your guinea pig receive daily supplements of Vitamin C?

Does your pet have any chronic or ongoing health problems? *

Please list your pet's chronic or ongoing health problems.

Is your pet on any medications? *

This can be prescriptions, over-the-counter medications, and supplements.

Please list your pet's medications below and dosage.

Please include name and dosage.

Do you plan on travelling out of state with your pet in the near future? *

When and where do you plan to travel?

Has your pet visited another veterinarian? *

Yes
No
I'm not sure

Please explain

Do we have your permission to contact them to acquire your pet's medical records? *

What is the clinic's name? *

What is the clinic's phone number?

Medical Records Note

To help us prepare for your first visit, please provide your pet's previous medical history before his or her appointment. You may email the history to info@visitingvetcare.com or fax it to 740-562-6633.

Consent to Share Medical Records

Name *

First

Middle

Last

First and Last are required.

Phone *

Email *

What is your pet's or pets' names that you wish to have us transfer records for? *

Please only list the pet or pets that you wish to have us transfer records for.

What is the name of the clinic, daycare/boarding facility, or individual that you wish to have us share your pet's or pets' records to? *

What is their phone number? *

What is the email address that they wish us to send your pet's records to? *

One time transfer *

I attest that I am the owner of the animal listed above. I give Your Visiting Veterinarian LLC permission to do a one-time transfer of my pet's or pets' medical records to the clinic, hospital, or individual listed above via the email address that I have provided above.

Acknowledge *

I attest that this information is correct and accurate and I release Your Visiting Veterinarian, LLC from any liability or wrong-doing that may occur from the transfer of my pet's or pets' records.

Signature

New Avian Patient Form

Owner's Name *

First

Middle

Last

First and Last are required.

Phone *

Email *

Bird's name *

Breed *

Color *

Bird's Gender *

Male
Female

What is your bird's birthday or approximate age? *

Where did you get your bird? *

Reason for our mobile vet visit? *

What do you feed your bird? *

Please include the brand of bird food and include table scraps and treats if applicable.

How much food does your bird get fed? *

How does your bird react to visitors coming to your house? *

I.E. Friendly, Excited, Fearful, Aggressive, etc.

Does your bird spend any time outdoors? *

Does your bird have any cage mates or other pets in the home? *

Please Explain

Do you have any supplemental UVA/UVB lighting for your pet? *

Does your bird have any chronic or ongoing health problems? *

Please list your bird's chronic or ongoing health problems.

Is your bird on any medications? *

This can be prescriptions, over-the-counter medications, and supplements.

Please list your bird's medications below and dosage.

Please include name and dosage.

Do you plan on travelling out of state with your bird in the near future? *

When and where do you plan to travel?

Has your bird visited another veterinarian? *

Yes
No
I'm not sure

Please explain

Do we have your permission to contact them to acquire your bird's medical records? *

What is the clinic's name? *

What is the clinic's phone number?

Medical Records Note

To help us prepare for your first visit, please provide your bird's previous medical history before his or her appointment. You may email the history to info@visitingvetcare.com or fax it to 740-562-6633.

New Feline Patient Form

Owner's Name *

First

Middle

Last

First and Last are required.

Phone *

Email *

Cat's name *

Breed *

Color *

Cat's Gender *

Male
Female

Is your cat spayed or neutered? *

Reason for our mobile vet visit? *

Is your cat microchipped? *

Would you like to have your cat microchipped?

What do you feed your cat ? *

Please include the brand of cat food and include table scraps and treats if applicable.

How much food does your cat get fed? *

What is your cat's birthday or approximate age? *

Where did you get your cat? *

How does your cat react to visitors coming to your house? *

I.E. Friendly, Excited, Fearful, Aggressive, etc.

Does your cat have allergies? *

What is your cat allergic to?

Does your cat have any chronic or ongoing health problems? *

Please list your cat's chronic or ongoing health problems.

Has your cat ever been tested for feline leukemia or feline immunodeficiency virus?

Yes
No
I'm not sure

Is your cat on any medications? *

This can be prescriptions, over-the-counter medications, and supplements.

Please list your cat's medications below and dosage.

Please include name and dosage.

Has your cat ever had a reaction to a vaccine or medication? *

Please list the vaccine and/or medication and approximate date.

Please include the name and dosage if possible along with approximate date.

Does your cat spend any time outdoors?

Do you plan on travelling out of state with your cat in the near future? *

When and where do you plan to travel?

Has your cat visited another veterinarian? *

Yes
No
I'm not sure

Please explain

Do we have your permission to contact them to acquire your cat's medical records? *

What is the clinic's name? *

What is the clinic's phone number?

Medical Records Note

To help us prepare for your first visit, please provide your dog's previous medical history before his or her appointment. You may email the history to info@visitingvetcare.com or fax it to 740-562-6633.

New Canine Patient Form

Owner's Name *

First

Middle

Last

First and Last are required.

Phone *

Email *

Dog's name *

Breed *

Color *

Dog's Gender *

Male
Female

Is your dog spayed or neutered? *

Reason for our mobile vet visit? *

Is your dog microchipped? *

Would you like to have your dog microchipped?

What do you feed your dog? *

Please include the brand of dog food and include table scraps and treats if applicable.

How much food does your dog get fed? *

What is your dog's birthday or approximate age? *

Where did you get your dog? *

How does your dog react to visitors coming to your house? *

I.E. Friendly, Excited, Fearful, Aggressive, etc.

Does your dog have allergies? *

What are they allergic to?

Does your dog have any chronic or ongoing health problems? *

Please list your dog's chronic or ongoing health problems.

Is your dog on any medications? *

This can be prescriptions, over-the-counter medications, and supplements.

Please list your dog's medications below and dosage.

Please include name and dosage.

Has your dog ever had a reaction to a vaccine or medication? *

Please list the vaccine and/or medication and approximate date.

Please include the name and dosage if possible along with approximate date.

Do you plan on travelling out of state with your dog in the near future? *

When and where do you plan to travel?

Has your dog visited another veterinarian? *

Yes
No
I'm not sure

Please explain

Do we have your permission to contact them to acquire your dog's medical records? *

What is the clinic's name? *

What is the clinic's phone number?

Medical Records Note

Contact Form

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