TCVM Pet Intake Form
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Owner's Name
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Your answer
Street Address
Your answer
City
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Your answer
State
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Your answer
Zip
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Your answer
Phone
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Your answer
Email
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Your answer
Pet's Name
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Your answer
Species
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Dog
Cat
Other
Sex
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Male
Female
If an Intact Female, is she (could she be) pregnant ?
Yes
No
Clear selection
Age
*
Your answer
Weight
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Your answer
Color
Your answer
Breed
Your answer
Primary Care Veterinarian
Your answer
Major Complaint (s)
Your answer
Medical History and Current Medications
Your answer
Date of Last Rabies Vaccination
*
MM
/
DD
/
YYYY
How long has your pet been ill ?
Your answer
What makes it better or worse ?
Your answer
Have you noticed a change in mood, attitude or awareness ? If yes, please describe.
Your answer
Does your pet prefer to be warm or cold ?
Warm
Cold
No preference
Clear selection
Does your pet pant more than normal ?
No
Yes
Yes and more heavily at night
Clear selection
Urination
Urinating in the house or outside the litter box
Dribbles urine throughout the day
Dribbles urine in bed overnight
Difficultly urinating
Urine has changed color
Urine has a strange smell
Defecation
Defecating in the house or outside the litter box
Difficultly Defecating
Diarrhea
Constipation
Have you noticed a change in your pet's bark or meow ?
No
Yes, Weaker
Yes, Vocalizing more than normal
Have you had a change in your home ?
Recent move
Loss of family member or another pet
New person or animal to the household
Is this issue seasonal ?
No
Yes, Spring
Yes, Summer
Yes, Fall
Yes, Winter
On a scale of 1 to 5, Rate the severity of your pet's condition
Mild
1
2
3
4
5
Severe
Clear selection
Current Diet
Your answer
Fire Element Personality Traits
Lively
Communicative
Very Friendly with everyone including strangers
Loves to be Groomed
Loves to be in the show ring
Diva
Fire Element Imbalances
Insomnia
Separation Anxiety
Restless
Always Hot
Heart Disease - congenital defect, murmur, arrhythmia, ect
Earth Element Personality Traits
Laid Back, Lazy
Sociable, Friendly with other animals and people
Solid - Chubby, Well muscled, Big boned
Loyal
Food Motivated
Motherly - Cares for others
Can be stubborn if they think you are being unfair
Earth Element Imbalances
Diarrhea
Constipation
Loss of Appetite
Vomiting
Gum Disease
Weak Muscles
Over eater - Obese
Worried
Metal Element Personality Traits
Likes to have a daily routine
Obeys the rules
Aloof
Does not like Change
Disciplined Attitude
Very Trainable
Metal Element Imbalances
Breathing disorder
Allergies
Cough
Dry Skin
Immune mediated disease
Water Element Personality Traits
Careful
Curious
Does not like strangers
Afraid of new things/loud noises
Submissive to other animals
Water Element Imbalances
Panic Attacks
Rear limb weakness
Arthritis
Back Pain
Urinary Problems
Deafness
Abnormal growth - angular limb deformity, small, frail
Reproductive problems in breeding animals
Wood Element Personality Traits
Assertive
Confident
Strong
Impulsive
Athletic
Alpha in pack
Wood Element Imbalances
Tendon and/or Ligament Problems
Liver Disease
Eye Problems
Angry/Agressive
Ear Disease/Infection
Nail Problems
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.
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Yes
I understand that after submitting my form I must contact Holistic Veterinary House Calls if I would like to schedule an appointment.
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Yes
I understand that typing my name below will serve as my digital signature. (Please type your full name)
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