Owner's Name *

Street Address

City *

State *

Zip *

Phone *

Email *

Pet's Name *

Species *

Sex *

If an Intact Female, is she (could she be) pregnant ?

Age *

Weight *

Color

Breed

Primary Care Veterinarian

Major Complaint (s)

Medical History and Current Medications

Date of Last Rabies Vaccination *

How long has your pet been ill ?

What makes it better or worse ?

Have you noticed a change in mood, attitude or awareness ? If yes, please describe.

Does your pet prefer to be warm or cold ?

Does your pet pant more than normal ?

Urination

Defecation

Have you noticed a change in your pet's bark or meow ?

Have you had a change in your home ?

Is this issue seasonal ?

On a scale of 1 to 5, Rate the severity of your pet's condition

Current Diet

Fire Element Personality Traits

Fire Element Imbalances

Earth Element Personality Traits

Earth Element Imbalances

Metal Element Personality Traits

Metal Element Imbalances

Water Element Personality Traits

Water Element Imbalances

Wood Element Personality Traits

Wood Element Imbalances

I consent to the examination of this pet by staff veterinarians and chiropractors at Holistic Veterinary House Calls. I also agree that after consultation with me, the doctors may prescribe medication for, treat, sedate, perform acupuncture, perform chiropractic adjustments, and/or perform laser therapy on my pet. Given the sometimes unpredictable nature of house calI visits I understand that appointment times are approximate (+/- 30 minutes) and that flexibility is important. I understand that some risks always exist with any treatment and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. I have reviewed all treatment package fees on the website and understand that I am encouraged to discuss all fees related to such care before services are rendered including during my pet's ongoing medical treatment. I understand payment is due at the time of service or when electronic invoice has been emailed. I understand that late payment may be sent to collections after 30 days. I also consent to sharing my pet's records when a referral is necessary. *

I understand that after submitting my form I must contact Holistic Veterinary House Calls if I would like to schedule an appointment. *

I understand that typing my name below will serve as my digital signature. (Please type your full name) *