Please note: We will be closed from July 6th to July 22nd, and will resume normal business on July 24th.

Patient Consent

Thank you for considering House Call Vet RVA for your pet’s needs.

Patient Consent Form

Please fill out our patient consent form in its entirety to ensure we can provide you and your pet with the best possible care. Please note: Any fields with * are required.

Owner Information
Name*
Prefix First Last
Email*
Mobile Phone*
Home Phone
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Driver’s License Number*
Driver’s License Expiration Date*
MM slash DD slash YYYY
Your Date of Birth*
Month
Day
Year
Spouse/Co-Owner's Name
First Last
Spouse/Co-Owner's Phone Number
Pet Information
Pet's Name*
Pet's Date of Birth*
Species*
Breed*
Color*
Sex*
Patient's Medical Record
Drop files here or

Max. file size: 256 MB.
Add another pet?*
- Yes
- No
Pet's Name*
First
Pet's Date of Birth*
Month
Day
Year
Species*
Breed*
Color*
Sex*
Patient Medical Record
Drop files here or

Max. file size: 256 MB.
Add one more pet?*
- Yes
- No
Pet's Name*
First
Pet's Date of Birth*
Month
Day
Year
Species*
Breed*
Color*
Sex*
Patient Medical Record
Drop files here or

Max. file size: 256 MB.
This field is hidden when viewing the form
Consent For Treatment
Consent for Treatment*
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.
By checking this box, I have authorize House Call Vet RVA, PLLC and staff to provide medical care for the aforementioned pet(s)
Financial Policy Agreement*
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 am aware that estimates are provided upon request. Accepted payment methods include cash, debit card or credit card (VISA, Mastercard & American Express).
I agree
Virginia Veterinary Disclosure (please note a hard copy will be brought to your pet's appointment for signing as this is required)*
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, 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 as an ambulatory veterinary facility. Services are provided through appointment only. Veterinary care is not guaranteed to be available outside a scheduled appointment time.
by checking this box, I have read and and fully understand the above disclosure*
Social Media Consent
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.*
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.
- I agree
- No thank you
Owner/Agent's Signature
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.*
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.
Date of Authorization*
Month
Day
Year
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.
By signing and typing my full name below I agree to signing this authorization form electronically.*
Name*
First Last

Please note: We will be closed from July 6th to July 22nd, and will resume normal business on July 24th.

Patient Consent

Patient Consent Form

Owner Information

Pet Information

Consent For Treatment

Social Media Consent

Owner/Agent's Signature

Electronic Signature Agreement

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