New Patient Form: Palliative and End of Life Care

Owner first name(s)

Owner last name

Email

Primary Phone Number

Secondary Phone Number (optional)

How would you like to receive information or communication from us?

Text

Email

Phone call

No preference

Your address:

Multi-line address

Country/Region

Address

City

Zip / Postal code

From which veterinary clinic(s) can we request your pet's medical records?

Do you authorize Red Sage to contact the above veterinary clinic(s) to obtain your pet's medical records?

Yes

No

Would you like us to share your Red Sage medical records with the above veterinarian?

Yes

No

Do you have pet insurance? If so, which company?

Pet's Name

Pet's Breed

Pet's date of birth or approximate age

Male or Female? Spayed/Neutered?

Scheduling Preferences: Please provide us with some preferred days and times for appointments. Because our schedule books in advance, we cannot guarantee availability but we will do our best!

What are your main goals in coming to Red Sage for palliative care?

Are there changes in your pet's appetite/mobility/behavior that you've noticed?

Do you have previous experience with a pet passing?

What questions do you want answered in your first visit?

Please provide a detailed list of your pet's medications and supplements, including frequency and dosing. (e.g. Rimadyl 50mg twice daily for the last 2 months)

Is there anything else you would like us to know about your pet? (E.g. allergies, fears, loves/preferences, commands, etc.)

Are you comfortable with your pet's picture or story being shared with others via social media or our website?

YES

NO

Please read our privacy policy by clicking here. Sign below to agree to this policy.

Signature

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I ACCEPT text communications with Red Sage.

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