Yonder Care Quality Of Life Assessment ConsentFill this out ahead of your appointment. Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Pet's name * Pet's species * My pet is a: * intact female spayed female intact male neutered male Pet's approximate age * Pet's approximate weight * Pet's breed * Pet's color/markings * Pet's presenting complaint * Pet's regular/referring veterinarian/clinic * To the best of my knowledge the above information is correct, and I agree to the cost of $110 for a house call quality of life assessment, physical exam and end of life and/or hospice planning for my pet. * By checking this box, I agree to the terms and conditions outlined above. Type your name here to serve as an electronic signature * Thank you! We will be in touch prior to your appointment if we have questions, then you can expect a phone call when the veterinarian is on the way to you. When the veterinarian arrives, you will be presented with a paper copy of this form with your information and answers already filed in - all you have to do before the appointment starts is sign the document and make payment if you haven’t already done so online or over the phone.
