New Patient Information

Hey there, Welcome to Wildflower!

Tell us a little about you!

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Preference For Contact *

When do we get to meet you?

Date of Appointment: *

Any details we need prior to arrival? *

Tell us about your pets!

First Pet Name, Age, Breed, Approximate Weight *

Needs/Concerns at Visit for this Pet: *

Any significant medical history or current medications for this pet? *

Second Pet Name, Age, Breed, Approximate Weight *

Needs/Concerns at Visit for this Pet: *

Any significant medical history or current medications for this pet? *

Third Pet Name, Age, Breed, Approximate Weight *

Needs/Concerns at Visit for this Pet: *

Any significant medical history or current medications for this pet? *

Information about any other pets we are seeing: *

Do you have previous medical records? Attach here! *

Max file size: 20MB

Help us prepare for the BEST visit!

Any previous anxiety or aggression at the vet? *

Is there anything that has made home visits in the past successful? *

Let's make it legal!

Do you consent to treatment by Wildflower Veterinary Mobile Services, PLLC during the appointment you have requested? *

Yes No

Do you confirm that a legal family representative above the age of 18 will be at the home for the scheduled visit? *

Yes

Electronic Signature & Date *

Anything else you would like us to know prior to your appointment? *

We appreciate you taking the time to help Wildflower prepare for your visit - we look forward to seeing you soon!

Submit

Quick Links:

Appointment request:

Hospice Consult Request

Home Euthanasia Request

email for questions:

Email Link

Appointments are seen evenings and weekends.

Emails are answered or returned during normal business hours when we are not in other appointments. Please provide as much information as possible to help us serve you in a more timely manner.

Know that we are thinking of you and your family during this tough time. There is no good way to say goodbye, but being able to be together in the comfort of your own home is one of the sweetest gifts. We are glad to help with any questions you may have.

Thank you for letting us help walk these last few steps with you and your family - Dr. Desiree & the Wildflower team