Additional Pet Visit Request Please complete this form for each additional pet you are requesting a visit for. Phone * (###) ### #### Pet's Name * First Name Last Name Pet's Birthday * Estimated MM DD YYYY Species * Canine Feline Breed * Reproductive Status * Neutered Male Spayed Female Intact Male Intact Female Relevant Health History * Reason for Visit * Wellness Exam Illness or Injury Other Name and Phone Number of Previous Vet Hospitals * To request pet medical history How Did You Hear About Us? Treatment Consent & Liability Acknowledgement * Consent & Liability Acknowledgement I certify that I am the lawful owner or authorized guardian of the above‑named pet(s) and give permission for Apawthecary and Dr. Taylor Campione to provide veterinary care in my home. I understand: There are risks associated with in‑home veterinary care, including unexpected complications. I agree to fully disclose any known health issues, medications, allergies, or behavioral concerns. I am responsible for following all treatment and post‑care instructions. I release Apawthecary and Dr. Taylor Campione from any liability for outcomes resulting from the in‑home care performed today, except in cases of gross negligence or willful misconduct. I have read and agree to the Treatment Consent and Liability Agreement above Electronic Signature * Please type your legal full name as an electronic signature Date * MM DD YYYY Please Note: I do not offer emergency services. If your pet is experiencing a life-threatening emergency, immediately contact and visit your nearest emergency veterinary hospital and/or your pet’s primary care veterinarian.
