Commonly Used Forms

In order to provide each individual patient with the best care, resources and individualized services, please use the forms below to get in touch!

  • - Please note allow 48-72 hours for the doctor to review your pet's medical records. We will contact you once the request has been authorized or declined. - If you choose to order from an online pharmacy, please note, in accordance with best practices and national guidelines, we will mail a written script to your home. address. From there you are able to submit the prescription authorization to the pharmacy of your choosing.
  • You can upload a picture of your current prescription or product to make sure you get the correct item.
    Drop files here or
  • Please select any that apply to your pet and explain on provided comment line at the end:

  • Behavioral Questionnaire

  • Almost Done!

  • Please include your pet's daily food amount, frequency, form (kibble or canned). Please also include any treats your pet receives.
  • Please list ALL medications your pet receives, including monthly preventatives. Make sure to include the dose, frequency and name of each medication.
  • If you do not have your pet's records readily available, please have them emailed to info@housecallvetrva.com at least 24 hours prior to your pet's scheduled appointment
  • This image will be used on the pet's medical record and not shared with the public
  • Please include any food and/or medication sensitivities. Please also include any adverse reaction to vaccines, medications or any other substance.
  • This field is for validation purposes and should be left unchanged.
  • Client Information

  • Patient Information

  • Authorization for Humane Euthanasia Services

  • I have read and understand this authorization. To the best of my knowledge, the information I have provided is true. I understand that these services will be carried out at the scheduled or agreed upon appointment time. Fees for these services have been explained to me and I am aware payment is due in full prior to, or if authorized by Dr. Kaitlyn Hemsley, at the scheduled appointment time.
  • Electronic Signature Agreement

    The parties agree that the electronic signatures appearing on this form are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
  • This field is for validation purposes and should be left unchanged.
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  • This field is for validation purposes and should be left unchanged.