Pet Hospice Virtual Quality of Life Form

Owner Name*
Co-Owner's Name
Primary Phone*
Email Address*
Address*
Apt. #
City*
State*
ZIP code*
Pet's Name*
Species*
Breed*
Color*
Date of Birth (mm/dd/yyyy)*
MM slash DD slash YYYY
Weight*
Sex*
- Female Intact
- Female Spayed
- Male Intact
- Male Neutered
Describe reason you are seeking a virtual consultation*
Please list your pet's veterinarian(s) or hospital(s).*
How did you hear about us?
Consent for Services
Our Quality of Life evaluations are non-medical in nature, meaning we cannot diagnose conditions, make medical recommendations, or prescribe medications.
Records and Communication Policy
BluePearl Pet Hospice is part of your pet’s continuum of care, and we may provide your family veterinarian, any specialists, and/or a reviewing body information regarding your pet’s treatment and/or condition. You are authorizing BluePearl Pet Hospice to share your pet’s medical record with a third party (such as your family veterinarian) or its agent necessary for us to provide continuous veterinary care to your pet. You agree that we (or our agents) may send you communications to your contact information provided above regarding your pet.veterinarian) or its agent necessary for us to provide continuous veterinary care to your pet. You agree that we (or our agents) may send you communications to your contact information provided above regarding your pet.
Client Signature*
Date*
MM slash DD slash YYYY
Data Privacy Notice
BluePearl Pet Hospice 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 clinical studies, diagnosis and analysis from across our veterinary 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 Pet Hospice, and our affiliates, may also use the data collected from you and your pet for advertising and promotion of goods and services that may be of interest and beneficial to you and your pet, and we may use such data and/or any residual biological samples collected from your pet for clinical studies to advance veterinary knowledge. Please visit our privacy policy at https://www.mars.com/privacy for more information about the collection and use of your data. You may have the right to request deletion of your personal information, access to your information, to opt-out of certain sharing of your personal information, and more. To do so, please contact us at 1-855-900-8444, or c/o Data Analytics, 2950 Busch Lake Blvd., Tampa, Florida 33614. Please note that, notwithstanding your request, we may still retain certain categories of personal information for numerous purposes, including without limitation, to comply with certain legal obligations, such as record retention requirements.
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Pet Hospice Virtual Quality of Life Form

Consent for Services

Records and Communication Policy

Data Privacy Notice