TCVM Pet Intake Form
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 ?
Clear selection
Age *
Weight *
Color
Breed
Primary Care Veterinarian
Major Complaint (s)
Medical History and Current Medications
Date of Last Rabies Vaccination *
MM
/
DD
/
YYYY
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 ?
Clear selection
Does your pet pant more than normal ?
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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
Mild
Severe
Clear selection
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) *
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