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Information

Select a Pet Hospice Location*

First Name*

Last Name*

Phone Number*

Email Address*

ZIP Code*

Pet's Name*

Species*

Cat

Dog

Other

Breed*

Please type another option here

Sex*

Age or Birthdate*

Please list your pet's veterinarian(s) and/or hospital(s)*

When was your pet's most recent rabies vaccine?*

Which clinic administered this rabies vaccine?*

Behavior History

How long have you had this pet?*

Has your pet ever bitten anyone?*

Yes

Please share the details about your pet's bite history. If there are multiple incidents, please be sure to include details about each event.*

What was the date of the last bite incident?*

What other behaviors does your pet display that are problematic or unsafe?*

My pet is potentially aggressive with (please check all that apply):*

Adults

Children

Dogs

Other Pets

Behavior Intervention History

Have you spoken with your pet's primary veterinarian about these issues? If so, please share your veterinarian's thoughts regarding your pet's behavior.*

Has your pet ever been given medications for these behavioral issues? If so, please list the name of the medication, the dosage, the frequency, and the date that medication was started (and stopped, if applicable).*

Is your pet currently on any medications for any other reasons? If so, please list the name of the medication, the dosage, the frequency, and the date that medication was started.*

Have you sought behavioral treatment for your pet either through a regular veterinarian, a trainer, or a board-certified veterinary behaviorist?*

Yes

Please describe the behavioral treatment you have sought.*

Appointment Logistics

Are you able to place a muzzle on your pet, if needed?*

Yes

Are you comfortable giving, either in food or by administering orally, a large (20-100 pills) amount of oral sedation medications to your pet?*

Yes

Are you able to safely apply a tasteless gel to the inside of your pet's lips, either by using a gloved finger or a syringe without a needle?*

Yes

Client Signature*

Your Name
Your Name
Your Name

Date*

Data Privacy Notice

BluePearl and our affiliated entities are committed to providing quality and informed services to and for you and your pet. We aim to be your partner in your pet's long-term health and happiness through a variety of means, including by considering research, diagnosis and analysis from across our vet hospitals and brands. As part of this mission, we work with our affiliates, parent and subsidiaries to provide the services you request and to analyze and evaluate the patterns of diagnosis and treatment of the pets treated at our facilities. From time to time we, BluePearl, and our affiliates, may also use the data collected from you and your pet for research and for advertising and promotion of goods and services that may be of interest and beneficial to you and your pet. For more information on our policies and information on how to opt-out of some forms of sharing, please see our Privacy Policy at https://www.mars.com/privacy.

Behavior Questionnaire

Information

Behavior History

Behavior Intervention History

Appointment Logistics

Data Privacy Notice