New Client Form for Avian

New Client Form

Thank you for the opportunity to care for your beloved pet. Our goal is to treat your pet with the same love and quality care that we would with our own, and to provide the highest quality service. We take an integrative approach for the best health care with strong emphasis on nutrition as a base for excellent health. Please help us meet your needs and the needs of your pet by sharing the following important information:

Pet Owner's Name: First Name *   Last Name *

Address: Street Address
City   State   Zip

Home Phone:    Phone Number Cell Phone: Phone Number

Email Address:   Email *

Employer:      Work Phone: Phone Number

Significant Other or Co Owner:

Name: First Name    Last Name

Cell Phone: Phone Number

Email Address: Email

Emergency Contact:

Name: First Name Last Name

Cell Phone: Phone Number

How did you hear about us?:

Or referred by (We would like to thank them):

May we take photographs of your pet(s) for educational purposes or for our social media? We will not release personal information such as your name :

Pet's Name:

Date of Birth/Approximate Age:

Species:

Color/Markings:

Sex:

Duration in owner's care?:

Origin (captive bred, wild import):

Source (Breeder, Pet Shop, etc):

What type of cage / enclosure does your bird have (approximate size)? :

Where in the house is the cage located?:

Does your pet spend time outside the cage?:

If Yes, How much? / Where?:

Are other birds sharing the cage? Or in direct contact?:

How often is the enclosure cleaned, and what products are used?:

What kind of food do you feed your bird?
Please specify types/brands, how often, and percent of daily diet (0%-100%).

Pellets: type    How often: frequency % of Diet:%

Seed Mix: type  How often: frequency  % of Diet:%

Fruits: type   How often: frequency % of Diet:%

Veggies: type   How often: frequency % of Diet:%

Treats: type   How often: frequency % of Diet:%

Other: type   How often: frequency % of Diet:%

Do you give your bird supplements?
Kind and frequency:

Supplement: type    How often: amount

Supplement: name   How often: amount

Supplement: name   How often: amount

Please list any previous medical problems:

Has your bird ever been tested for:

Has your bird been recently exposed to other birds? (new bird, boarding, etc):

Is your bird groomed regularly?:

Do you bathe your bird?:

If so, how often?

Does your bird have a full spectrum (UVB) light?

If so, what brand?

Have there been any changes in the bird's environment?

Does your bird have any behavior problems?

Have you noticed any of the following?
If so, please describe:

Decreased appetite / Increased appetite: type

Anorexia: explain

Weight gain / Weight loss: explain

Vomiting / Regurgitation: explain

Difficulty Breathing: explain

Tail Bobbing: explain

Lethargy: explain

Fluffed Feathers: explain

Diarrhea: explain

Feather Picking: explain

Nasal or Eye Discharge: explain

Are there any smokers in the house?

Have there been any changes in your bird's droppings? Please Describe:

(number, color, consistency).

Name of Hospital/Clinic where records can be obtained?:

Hospital/Clinic: name* Phone: #*

Email: Email

*Many hospitals/clinics require owner release of their pet's records

Is your pet covered under any pet insurance?:

Would you like information on Veterinary Pet Insurance?:

Is there anything else you would like to mention or have concerns about?:

We gladly provide a written Health Care Plan with associated professional fees. This will be important to you since ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. In cases of extensive medical or surgical procedures, when full payment may be difficult at discharge, we accept Visa, Mastercard, American Express, Discover, or Care Credit.

Alternative Therapy Consent

The following are considered to be alternative therapy in veterinary medicine, and are used in conjunction with other conventional treatments that are available in veterinary medicine. All require a valid veterinarian / client / patient relationship and an examination by the veterinarian to determine that the treatment will not harm the patient.

Chiropractic and other forms of Musculoskeletal Manipulation are systems of therapeutic application of mechanical forces applied manually through the hands or any mechanical device to treat and/or alleviate impaired or altered function of related components of the musculoskeletal system of nonhuman animals. A non-veterinarian employee or an independent contractor may perform these procedures on an animal under the direct or general supervision of the veterinarian.
Acupuncture:
- Only licensed veterinarians may use acupuncture in the care and medical treatment of animals.
- The insertion of an acupuncture needle and the application of moxibustion to specific areas of a nonhuman animal’s body to relieve the discomfort associated with painful disorders, to induce surgical anesthesia, and for therapeutic purposes; and
- The administration of thermal or electrical treatments or the recommendation of dietary guidelines, energy flow exercise, or dietary or herbal supplements in conjunction with the treatment described by the preceding paragraph.
Holistic Medicine is the practice of veterinary medicine that believes in a blend of alternative and, if need be, conventional approaches of treatment in an effort to develop a system of complementary medicine to treat the whole patient. Only licensed veterinarians may use holistic medicine in the medical treatment of animals. In practice, it incorporates less conventional methods such as herbal medicine, acupuncture, chiropractic, homeopathy, and applied kinesiology, with more conventional methods, such as modern drugs, surgery and diagnostics.
Homeopathy is a system of therapeutics in which diseases are treated by substances which are capable of producing in healthy animals symptoms like those of the disease to be treated, the substance being administered in minute doses. Only licensed veterinarians may use homeopathy in the medical treatment of animals.
Class IV Laser Therapy is a safe and non-invasive treatment and has been cleared by the FDA to emit photon energy for the relief of minor muscle and joint pain, muscle spasm, pain and stiffness associated with minor arthritis, promoting relaxation of muscle tissue, and increase local blood circulation.

By signing this consent form, I am acknowledging that I am the owner of the animal noted above (or an authorized caretaker), and that I have been informed of conventional treatments that are also available and their probable ability to cure or treat the condition. Veterinarians who practice any form of Alternative Therapy shall exercise the same degree of humane care, skill, and diligence in treating patients as are ordinarily used in the same or similar circumstances by average members of the veterinary medical profession in good standing in the locality or community, or in similar locations or communities, in which they practice.

This signed statement will become a part of the medical record.

Signature

We are updating our Cancellation Policy

as follows:

As of May 1, 2024, all appointments with the Doctor will require a Scheduling Fee.

Scheduling Fees are non-refundable for cancellations made within 24hrs of the scheduled appointment time.

Cancellations made prior to the 24hr window may have a partial refund returned to the card used to make the payment (minus $14 Processing Fee).

***The full Scheduling Fee amount may be utilized as a Credit on Account for future services.

We appreciate your understanding as we strive to provide excellent service to our patients in need!

Optional:

Client Name: First Name * Last Name *

Client Signature:

Date:

Date

PET INFORMATION

Pet Insurance