Intake Form - Holistic Veterinary Healing

OWNER

Name:(Required)

Date(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Telephone Numbers:

Home

Work

Cell(Required)

Email Address:(Required)

How did you hear about Holistic Veterinary Healing?

PATIENT INFORMATION: General

Pet's Name(Required)

Breed:

DOB

Age

Hidden

Age old

Species(Required)

Canine

Feline

Sex(Required)

Female

Male

Altered(Required)

Yes

Unknown

Color:

How much time does your pet spend indoors and outdoors?

What specific brands of food and treats do you feed your pet?

What is your pet’s disposition? i.e. alert, shy, anxious, depressed, dominant, etc.

What medications and supplements do you give your pet?

CHIEF COMPLAINTS

What is the main reason for this visit?

When did it start?

What do you think caused this?

What is your goal for this appointment?

What forms of treatment have you tried?

What makes it better or worse? How is it affected by heat or cold, humidity, exercise, rest, pressure, being along, comforted, outside, etc?

What specific questions do you have?

MEDICAL HISTORY

Known allergies:

Known Medical Conditions:

Vaccines:

yes

unknown

not many

Date of last Rabies

Date of last Bordetella:

Date of last DHPPV

Other:

CANCELLATION POLICY

I acknowledge and agree to comply with the cancellation policy

If you do not show up for your scheduled appointment, and you have not notified us at least 24 hours in advance, you will be required to pay a missed appointment fee of $100. The missed appointment fee for any surgical or dental procedure is $275.

AUTHORIZATION FOR EXAMINATION, MEDICAL TREATMENT, AND FINANCIAL RESPONSIBILITY AGREEMENT

I agree to this consent and authorization form

I am the owner or agent of the above-described animal and have the authority to execute this consent. I request that Holistic Veterinary Healing perform the services which are necessary to the examination and medical treatment of the animal presented by me. I understand that Holistic Veterinary Healing is using mainly alternative methods of treatment (ACUPUNCTURE, HOMEOPATHY, SPINAL MANIPULATION, NUTRITIONAL SUPPLEMENTS, CHINESE HERBS, etc…), some of which may not be accepted as standard methods of treatment by the AVMA (American Veterinary Medical Association). I will request to have the nature and purpose of the procedures and alternative methods of treatment, the risks involved, and the possibility of complications fully explained to me if I am not already aware. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.

I understand that the treatment of the patient will be conducted with due loving care and in accordance with the prevailing standards of competency in holistic veterinary care as recognized by the AHVMA (American Holistic Veterinary Medical Association). I also understand that some procedures may be referred to specialists.

I assume financial responsibility for all charges incurred to the patient for services rendered and understand that full payment is required upon discharge. Accounts over 30 days past due shall be charged 1.5% interest per month, with a minimum of $4.50. I agree to pay all costs of litigation incurred in the collection of past due accounts. I understand that a written estimate of charges is available upon my request. This agreement shall remain in effect until such time as a different agreement is executed.

SIGNATURE OF OWNER OR RESPONSIBLE AGENT(Required)

DATE

PRINTED NAME OF OWNER OR RESPONSIBLE AGENT

This field is for validation purposes and should be left unchanged.