Intake Form

Your name:

Address:

City:

State/Province:

Zip/Postal Code:

Country:

Day Phone Number:

Evening Phone Number:

E-Mail:

Best time of day to reach you by phone:

Your Animal's Name:

Male Female

Neutered Spayed Not Fixed

Age:

List your animal's breed or all mixed breeds here:

If pregnant, how many months?

What is your animal's current health problem and how long has your animal had it?

Is there a western diagnosis?

Were blood tests, X-rays, sonograms, or other test results done to confirm the diagnosis?

When was the last time your animal was examined by a veterinarian?

List all vaccinations with dates:

List all conventional medical treatments with dates (procedures, medicines, surgeries):

Describe your animal's diet:

 
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