TCVM Pet Intake Form
If an Intact Female, is she (could she be) pregnant ?
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 ?
Yes and more heavily at night
Urinating in the house or outside the litter box
Dribbles urine throughout the day
Dribbles urine in bed overnight
Urine has changed color
Urine has a strange smell
Defecating in the house or outside the litter box
Have you noticed a change in your pet's bark or meow ?
Yes, Vocalizing more than normal
Have you had a change in your home ?
Loss of family member or another pet
New person or animal to the household
Is this issue seasonal ?
On a scale of 1 to 5, Rate the severity of your pet's condition
Fire Element Personality Traits
Very Friendly with everyone including strangers
Loves to be Groomed
Loves to be in the show ring
Fire Element Imbalances
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
Motherly - Cares for others
Can be stubborn if they think you are being unfair
Earth Element Imbalances
Loss of Appetite
Over eater - Obese
Metal Element Personality Traits
Likes to have a daily routine
Obeys the rules
Does not like Change
Metal Element Imbalances
Immune mediated disease
Water Element Personality Traits
Does not like strangers
Afraid of new things/loud noises
Submissive to other animals
Water Element Imbalances
Rear limb weakness
Abnormal growth - angular limb deformity, small, frail
Reproductive problems in breeding animals
Wood Element Personality Traits
Alpha in pack
Wood Element Imbalances
Tendon and/or Ligament 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.
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)
Never submit passwords through Google Forms.
This form was created inside of Holistic Veterinary House Calls.
Terms of Service