Palliative Care Intake Form

For security reasons please enter the phone number you provided when contacting our Client Care Team (without spaces, e.g. 0422157675).

Phone Number*

To ensure we maintain the highest standards of care, please check (and if needed update) your details below. We kindly ask that you provide any missing information.

Your Details

First Name*

Last Name*

Phone Number*

Email*

Street Address*

Suburb*

State*

Postcode*

Where should the vet park when they arrive at your home?*

Pet Details

Pet’s Name*

Species*

Breed*

Sex*

Age*

Weight (kg)*

Your Details Continued

Appointment Date

Appointment Time

Please list your Regular Family Vet Clinic(s)*

Please list any Specialist Hospitals or Emergency Hospitals you have visited*

How did you hear about Rest Your Paws?*

Disease & Illness

What is your understanding of your pet’s disease and how it may progress?*

Briefly describe any recent changes or symptoms that concern you (e.g. breathing, appetite, hygiene, weight loss)*

Has your pet's behaviour or personality changed? If yes, please briefly describe this for the vet.

Has your pet's mobility changed? If yes, please briefly describe this for the vet.

Describe your pet's resilience levels, particularly as it relates to dealing with illness.*

Quality of Life

How would you describe your pet’s quality of life at the moment?*

What are the three to five things that, currently or previously, make your pet the happiest?

Describe a ‘good day’

Describe a 'bad day’

What can your pet still do comfortably that makes you feel it’s not yet the right time to say goodbye?*

Caregiver Questions

How are you coping with your pet's illness and current care and treatment?

List some goals of care you have for your pet.*

List some boundaries you have for your pet's care.*

What are your greatest fears or concerns about your pet’s end of life journey?

What is your previous experience with end of life care? This can be pet or human and direct or indirect involvement.

Do you feel you have a good support system, including family, friends, community and other services?

Is there anything additional you would like your veterinarian to know prior to your appointment?

SAVE & CONTINUE