Thank you for requesting an appointment. Please complete the consent form below: Patient Consent Form - House Call Vet RVA Pet Owner Information Prefix * Prefix * - Select a Prefix Mr. Mrs. Ms. Dr. Other Prefix First Name * Last Name * Date * Home Phone Cell Phone * Email Address * Preferred Contact Method * Preferred Contact Method * - Preferred Contact Phone Call Email Address * Spouse's Name Spouse's Phone Patient Information Pet's Name * Species * Breed * Sex * Pet spayed or neutered? * Date of Birth * Color * Upload your pet's medical history documents. (optional) Drop a file here or click to upload your pet's medical history documents. Choose File Maximum upload size: 10MB Add a Pet Remove I am the owner or the agent of the animal(s) described above, and I have the authority to execute this consent. I have also been informed that there are certain risks and complications associated with any treatments and/or procedures of this type. They have been explained to me as well. I further understand during that during the course of the treatments or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures and/or referral to a stationary veterinary establishment. I assume responsibility for all charges incurred in the care of the animal. I also understand that all fees are due at the time services are rendered. I understand I will be responsible for additional collection fees if unpaid account is sent to collection agency. I m aware that estimates are provided upon request. Accepted payment methods include cash, debit card or credit card (VISA, Mastercard & American Express). Signature * Clear Date * Virginia Veterinary Disclosure: Please be advised that House Call Vet RVA, PLLC is an ambulatory facility. Neither the facility nor Dr. Kaitlyn Hemsley provides 24 hour service or monitoring. You have the option of transporting your pet to an emergency facility for care or if the doctor, Kaitlyn Hemsley DVM, feels that this is warranted, or you prefer continued care. Appointment times are offered, based on availability, between 8 a.m. to 9 p.m. Mondays, Tuesdays, Wednesdays, Thursdays, Fridays, Saturdays, and Sundays. Appointment requests within the aforementioned timeframes are not guaranteed and subject to change. House Call Vet RVA, PLLC is licensed through the Virginia Board of Veterinary Medicine for ambulatory veterinary care. Services are provided through appointment only. Veterinary care is not guaranteed to be available outside a scheduled appointment time. Signature * Clear Date * Authorizations The following Person(s) is/are authorized to make medical decisions for my pet/pets: Name Cell/Primary Phone Number Name Cell/Primary Phone Number Name Cell/Primary Phone Number Signature * Clear Date * By checking this box, I agree that the 'Signature' boxes above serve in place of my written signature for the purposes of this Patient Consent Form. eSignature Agreement * I Agree I hereby give House Call Vet, PLLC, the absolute and irrevocable rights to use my pet's name(s) and pictures on House Call Vet PLLC's website (www.housecallvetrva.com) and on House Call Vet PLLC's social media sites (Facebook, Instagram, Twitter) and google sites. I authorize the use of my name on any of the websites mentioned above. House Call Vet RVA, PLLC has the right to use my pet's name and pictures and my pet's name for display, public relations and marketing I hereby acknowledge receipt of adequate consideration and waive the right to charge for the use of pictures and my name or inspect or approve the images prior to any form use. Social Media Agreement * I Agree No Thank You reCAPTCHA Website/URL SUBMIT CONSENT FORM If you are human, leave this field blank.