Hospice Care Consent / Patient History”

Owner's/Agent's Name

Address

City

State

Zip

Home Phone

Additional Phone

Email Address

Companion Animal's Name

Breed

Color

Age

Weight (lbs)

DogCatOther

MaleFemaleSpayed/Neutered

If applicable, please provide the name of the veterinary clinic/hospital that referred you to us.
Veterinary Clinic/Hospital Name Phone

Have any other veterinarians seen your companion animal within the last 3 years
Veterinary Clinic/Hospital Name Phone

Hospice Patient History

Diagnosis of any diseases

Digestive System & Abdomen
VomitingDiarrheaConstipationWeight lossTumor/MassOther GI concern

Please describe:

Muscle & Bones
Arthritis/StiffnessSigns of PainLimpingTumor/MassOther concern

Please describe:

Pain Scale:
1 (normal)234 (can't walk)

Heart & Lung
CoughingSneezingDifficulty BreathingExercise IntoleranceTumor/MassOther concern

Please describe:

Skin
Odor/Itching/SoresTumor/MassOther concern

Please describe:

Head & Neck
Ear ProblemEye problemMouth/TeethOther

Please describe:

Nervous System
SeizuresNerve DamageDementia/Wandering/ConfusionOther

Please describe:

What are your top 3 health concerns?
1.
2.
3.

Current Medications (Including strength and how frequently you give it)

What does he/she eat?:

What things does he/she like to do?

Where does he/she sleep?

What is his/her daily environment like?

Who are the caregivers?

What are the daily challenges in providing care?

Partnering Clinics?

Does your pet have medical insurance?

What are your expectations for your pet during hospice care?

Do you believe in euthanasia or prefer assisted natural death?

Is there anything else I should know?

Hopice Care Consent

I certify I am the legal owner/authorized agent for the owner of the companion animal described above and give HousePaws In-Home Veterinary Care, and any authorized agents, staff, or representatives full and complete authority to examine, prescribe for and/or treat (“hospice care”) the above-described companion animal.

I agree HousePaws In-Home Veterinary Care, and any authorized agents, staff, or representatives shall not be liable for any direct, indirect, or consequential damages resulting from such hospice care.

I understand hospice care is focused on preserving quality of life for as long as possible and is NOT focused on curing medical conditions or providing routine veterinary care, surgical care and/or emergency treatment/transport.

HousePaws In-Home Veterinary Care has informed me if additional diagnostics, procedures and/or more aggressive hospice care are recommended for my companion animal at this time, and I have (check one):
Declined additional diagnostics, procedures and/or more aggressive hospice care.Accepted the recommendation(s), and HousePaws In-Home VeterinaryCare has made necessary referrals.

To the best of my knowledge, the information I have provided on this form is true and correct. I do also certify that this animal has not bitten, seriously scratched, or exposed anyone to rabies in the past 10 days. I understand that my wishes will be immediately carried out upon the signing of this agreement. Fees for these services have been explained to me and will be collected at the time of service.

I assume full responsibility for the actions of the companion animal described above and all charges incurred during his/her hospice care. I also understand all professional fees are due at the time hospice care rendered.

I have carefully read and fully understand the above provisions.

Owner/Agent Signature: (Please sign below.)

Name (print please)

Date