Name *

First Name

Last Name

Phone *

(###)

###

####

Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

My pet is a: *

Dog

Cat

Other

My pet is: *

Female, spayed

Female, intact

Male, neutered

Male, intact

Please provide any of your pet's recent relevant medical history: *

I will email my pet's records to info@yourvetconnection.com.

I do not have recent medical records for my pet.

Which of these statements apply to your pet? *

Check any/all that apply.

My pet has difficulty standing up or walking

My pet is not eating or has a very limited appetite

It seems like my pet is in pain.

My pet shows some signs of disorientation (confusion, wandering).

My pet has a diagnosed disease and is in declining health.

My pet is displaying concerning behavior.

Other, please elaborate below.

How soon would you like to schedule an in-home visit? *

Hospice consultations range from $150-$250 and include 3 months of unlimited telehealth consults for follow up guidance.

As soon as possible/urgent

Within 1 week

Within 2 weeks

This month

Already scheduled