Pet Parent *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is this your mailing address?

Yes
No

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Please upload a current picture of your pet(s) to be added to their patient records.

Click or drag a file to this area to upload.

What other family members will be involved in your pet's appointment?

Instructions - cross streets, house color, cars, etc. that will help us find your home:

Phone Number *

Receive texts at above number? *

Yes
No

Email *

Do you have a doctor preference for your next visit? *

How did you hear about us?

If you were referred by someone else, who should we thank?

What dates and times are you considering for your appointment?

Pet Information

Patient Name *

Pet's Date of Birth *

Exact date of birth or estimated date of birth? *

Exact
Estimated

Sex *

Male
Female

Is your pet spayed or neutered? *

Yes
No

Species

Cat
Dog

Breed *

Weight *

Enter weight in pounds.

Color *

How may we help you? *

Wellness Visit for Annual/Semi-Annual check up including vaccines and lab work
Illness Visit
Quality of Life/Hospice Planning and/or End of Life Care

May we help you with aftercare for your pet? *

Communal (no ashes returned to you)
Private (ashes returned to your veterinarian)
Traditional/flame-based
Aquamation
Home burial/managing body care and will not need cremation services

If your pet is 35-90 pounds, do you have one person who can safely help lift your pet on a stretcher? If your pet is over 90 pounds, do you have two people who can safely help lift your pet on a stretcher? (We may be able to provide an extra person with enough notice.) *

Yes
No
My pet weighs less than 35 pounds.

Do we have your authorization to post a memorial about your pet? Your pet's first name and an included photo would be the only identifier. *

Yes
No

If you would like, please upload a photo of your pet.

Click or drag a file to this area to upload.

Tell us a little about your pet's issue: *

Has your pet bitten (and broken skin) on a person in the last 10 days? *

YES, my pet has bitten.
NO, my pet has not bitten anyone in the last 10 days.

Photo & Video Approval

I hereby authorize The Welcome Waggin and its representatives to take photographs of my pet(s) during veterinary visits. I understand that these photographs may be used for marketing purposes, including but not limited to social media, websites, and printed materials. I further understand that no identifying information, including my pet's name, will be used without my consent.

I waive any right to inspect or approve the finished product, including written or electronic copy, wherein my pet's likeness appears. I also waive any right to royalties or other compensation arising or related to the use of the photographs.

I acknowledge that I am not entitled to any compensation for the use of these photographs and that I am not obligated to sign this waiver as a condition of receiving veterinary services.

Please check consent box below.

I agree that The Welcome Waggin can take photos of my pet and share them on our public social media pages.
I decline having my pets pictures be used.

APPOINTMENT

Ready for a visit?

Pet Information

Photo & Video Approval

Quality care in the comfort of your home.

Contact Info

SAY HELLO

Ready for a home visit?