Quality of Life Assessment Request

To request a quality of life assessment appointment, please fill out the following form. A team member will get back to you within 48 hrs to confirm appointment or request additional information, if needed.

If you would like to discuss your pet's specific medical conditions or diagnoses, please email all recent medical records (past 1-2 years) to haletoheaven@gmail.com at least 24 hrs prior to your scheduled appointment. This will allow doctor to review medical records prior to your appointment.

Type of Consult

Virtual

In-Person

Name

First Name

Last Name

Phone

(###)

###

####

Preferred Method of Contact

Text

Call

Pet's Name

Pet's Age (years)

Species

Dog

Cat

Has your pet been assessed by a veterinarian within the last year?

Yes

If so, please list name of the veterinary clinic and/or doctor

Please tell me about your pet's medical condition(s), any treatments or medications they are receiving, and any concerns you might have. Are there specific things you would like to explore or discuss during our consultation? The more information I have, the better I can guide and support you and your loved one

Requested Date/Time (First Choice)

Please select your preferred date and time for appointment (see business hours). In the event that your first choice is not available, please provide second and third choice options

YYYY

Time (AM/PM)

Second Choice Date/Time

YYYY

Time (AM/PM)

Third Choice Date/Time

YYYY

Time (AM/PM)