Contact Us & Forms - Your Visiting Veterinarian

New Small Mammal Patient Form

Owner's Name *

First

Middle

Last

First and Last are required.

Phone *

Email *

Pet's name *

Breed

Color *

Pet's Gender *

Male
Female
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? *

Yes
No

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

Yes
No

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

Yes
No

Is your pet on any medications? *

Yes
No

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

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

Yes
No

Has your pet visited another veterinarian? *

Yes
No
I'm not sure

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 Euthanasia

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? *

By signing this form:

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 by the methods I've selected using the contact information I have provided.

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

Consent to Telehealth

Name *

First

Middle

Last

First and Last are required.

Pet's name *

Phone *

Email *

I acknowledge the following:

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.

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Medical Records Note

I acknowledge the following:

Medical Records Note

Medical Records Note

Medical Records Note

Photo and Video Consent

24-Hour Cancellation Policy

No-Show Policy

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