Request a Consult Welcome to Hope Veterinary Oncology Services. We are grateful for the opportunity to help you and your loved one. To help you get answers and formulate a plan in the most efficient way, we perform our consultations virtually or via phone. Please complete this form ASAP and no less than 24 hours prior to your consultation. As a reminder, there is a $95 cancellation fee for appointments canceled with less than 24 hours notice. Thank you, Hope Veterinary Oncology Services 253-341-5835 info@hopeoncology.vet Owner Name(Required) First Last Do you have a Co-owner?(Required)NoYesCo-owner Name(Required) First Last Preferred Pronouns: Primary Phone:(Required)Email(Required) Does Hope Veterinary have permission to contact you at any of the following methods?(Required) Mail Phone Email Text message Deselect AllPrimary Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, 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Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is your billing address (tied to your credit card) the same as the address above?(Required)YesNo, it's a different addressBilling Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Pet's Name(Required) Pet Species(Required)CanineFelinePet Breed(Required) Pet Color(Required) Pet Gender(Required)Male (intact)Male (neutered)Female (intact)Female (neutered)Pet Date of Birth (Or Approximate Age)(Required) What Type of Cancer Does Your Pet Have?(Required) Please list any veterinary clinics that your pet has visited in the last year.(Required)Please list any medications and supplements that your pet is currently on. Please include strength and frequency of dosing.(Required)What diet is your pet currently receiving?(Required)Does your pet have any other significant medical conditions?(Required) Does your pet have any known allergies?(Required) What are your pets favorite activities and or toys?(Required)How would you describe your pet around other animals and people?(Required)Does your pet have any sensitive areas?(Required) Are there procedures that your Pet does not like having performed at a veterinary facility (e.g. nail trims, blood draw, temperature.)?(Required) Has your pet ever needed any prescribed medications or supplements to help with a visit to a veterinary hospital? If so, what were they?(Required) Is there anything else you would like us to know about your pet?Are there any cultural or religious beliefs that you would like us to be aware of that could impact the medical decisions for your pet while under our care? (please note this can be discussed in person if preferred and is not required to be answered.)MEDIA CONSENT: Does Hope Veterinary Oncology Services have permission to take photographs of your pet, and to copyright, use, or publish the same in print or electronically for educational or marketing purposes?(Required)YesNoToday's Date(Required) Please attach your favorite photo of your pet to be uploaded to their medical profile:(Required)Max. file size: 64 MB.Are You Located in Western Washington or Remote?(Required)Choose one:I am in Western WashingtonI am remote (outside of Western WA)INFORMED CONSENT FOR ALL OTHER PET OWNERS: by typing my name below, I acknowledge and understand the risks associated with teleconsulting, including that it may not be a complete solution for my pet and that I may need to seek additional in-person care. I also understand that an in-person physical exam and consultation provide the best setting for pet care, but I accept the risks and limitations associated with the consulting format. I also understand that Dr. Rizzo cannot diagnose or prescribe medications directly for my pet without an in-person physical exam.(Required) TREATMENT AND FINANCIAL CONSENT FOR PET OWNERS in WESTERN WA: by typing my name below, I do hereby certify that I am the owner or I’m assuming financial responsibility or otherwise for the Pet being presented. I understand that I assume any and all risks. I hereby authorize the doctor to examine, prescribe, and/or treat the pet described on this form. I assume full responsibility for all the charges incurred for the care of the pet. I understand that all charges are due at the time of service. (Required)(Required) For those outside of Western WA state, please attach your pet’s medical records. The last 6-12 months is usually sufficient. Please attach any physical exam findings, blood work results, biopsy reports, cytology reports and/or imaging reports.(Required)Max. file size: 64 MB.Your Total is $279.00. Please leave your credit card information. You will not be charged until after your consultation.Credit Card Number(Required) Expiration(Required) MM slash DD slash YYYY CCV (security code)(Required) NameThis field is for validation purposes and should be left unchanged.
