👤 Client NameFirstLast☎️ Phone *✉️ Email *Address: *postal code City EMERGENCY CONTACT *FirstLastPhoneI HEREBY CONSENT FOR THE ABOVE PERSON TO ACT ON MY BEHALF FOR THE TREATMENT, INCLUDING FINANCIAL CONSENT, OF ANY OF MY PETS.YesNoPet TypeDogCat🐶 ANIMAL INFORMATION Pet Name *SpeciesCanine FelinesexMaleMale neuter FemaleFemale spayedBreedColourPet WeightPet BirthdayPet AgeLess than one year1 year old2 years old3 year old4 years old5 years old6 years old7 years old8 years old9 years old10 years old11 years old12 years old13 years old14 years old15 years old16 years old17 years old18 years old19 years old20 years old21 years old22 years old23 years old24 years old25 years old26 years old27 years old28 years old29 years old30 years oldCheck the conditions that apply to your pet:CoughingSneezingVomitingDiarrchargeEye DischargeNasal DischargeLimpingSkin IssueNew or changed lumpTrouble breathingTrouble UrinatingWeight gainWeight lossChange in activity/ energy levelNo ConcernsOtherMedication Reasons for the visit , How long has this condition been going on for, and with what frequency?Has your pet ever had a reaction to vaccines?YesNoWhich preventative care or procedures are you approving?EuthanasiaBlood workOtherAre there any other issues or concerns that you would like to discuss at your appointment?How did you know about us?Authorization: * I authorize Toronto in Home Pet Euthanasia and Hospice Services to do whatever is necessary should an emergency arise. Should my pet become ill or injure itself, and Toronto in Home Pet Euthanasia and Hospice Services is unable to contact me or my emergency contact at the phone numbers provided, my pet will be treated as deemed necessary by the attending DVM at my own expense. *YesNoI have read and authorize Toronto in Home Pet Euthanasia and Hospice ServicesNameSubmitToronto in Home Pet Euthanasia and Hospice Services
