Registration Form - Acu Braun Veterinary Housecalls

Registration Form - Braun Veterinary Housecalls

WE KNOW YOUR PET’S HEATH IS IMPORTANT AND WE THANK YOU FOR TRUSTING US TO CARE FOR THEM. TO HELP USPROVIDE THE BEST CARE POSSIBLE, PLEASE TAKE A FEW MOMENTS TO FILL OUT THIS FORM COMPLETELY. THANK YOU!
Name *

First Name Last Name
Co-Owner Name

First Name Last Name
Primary Phone Number
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Co-Owner Phone Number
Please enter a valid phone number.
Email *
example@example.com
Occupation and/or employer
example@example.com
Co-owner occupation and/or employer
example@example.com
Preferred Method of Contact

Text Message Email Phone Call ANY
Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Postal Address IF DIFFERENT

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Any parking requests/restrictions
How did you hear about us
Name of Pet *
Type a question *

Dog Cat Other
Sex *

Neutered Male Intact Male Spayed Female Intact Female
Breed *
Color *
Birth Date or Age *
Describe your pet in a few sentences.
Up to date on rabies vaccination? *
Date of last vet exam?
Current veterinarian: *
Please describe any symptoms you are noticing: *
Current Medications and Supplements:
Any diagnostic tests done (x-rays, MRI, CT, Joint taps, etc)?
Any other current medical issues or pertinent medical history?
Any dietary restrictions or are treats allowed?
Any known bite history or aggressive behaviors? *

Yes No
If yes, please describe:
Does your pet dislike being touched anywhere in particular ( feet, ears, mouth,etc). *

Yes No
If yes, please describe:
Any other pets in the household?
Do you give permission for photos/videos of your pet and their health story to be used for social media, speaking engagements, and promotional materials for Dr Jana Braun?

Yes No
AUTHORIZATION
I hereby authorize Dr Braun to perform an exam and acupuncture.
Per WA Law WAC 246-933-345 You need to be aware of any potential outcomes from any treatment: There are rarely adverse effects to dog acupuncture treatments. Occasionally, symptoms may worsen for a day or two, as the energy in the body is being redirected and internal healing begins. You may notice a small bruise at needle locations, although with animals, you are unlikely to see anything. Although there are no reports in contemporary veterinary literature of injury or infection in animals resulting from acupuncture, in rare instances it’s possible that puncture of an organ or vessel could take place.
I certify that I have not been made any medical promise of success or guarantee of outcome of service. I understand that every medical condition is different and outcomes are based upon multiple factors. I authorize the veterinarians of Braun Veterinary Services, PLLC, d.b.a. Braun Veterinary Housecalls and their support staff, to administer such treatment and/or perform such diagnostic as deemed necessary.
This authorization serves for today and further treatments unless revoked in writing.
Signature *

Clear
Cold or low level laser therapy helps with pain and healing. However, there is a chance it can perpetuate any cancerous lesions.Does your pet have any known or suspicious areas of cancer? Or a history of cancer or tumors?

Yes No
If yes, please describe:
Please sign if you understand these risks and would like to proceed with low level laser therapy. I will provide laser protective glasses for you and your pet. You agree to wear them.

If you pet does not tolerate them, you understand the very small risk of eye damage if he/she looks directly at the laser.
Please let me know if there are areas on your pet you would like avoided.
Signature

Clear
COVID STATEMENT
I understand the risks presented by potential necessary close contact with Dr. Jana Braun. I will not hold Dr. Braun or Braun Veterinary Housecalls responsible for any potential exposure to COVID-19

If I am not vaccinated, I will wear a tight-fitting mask over my nose and mouth during the entire encounter. I will maintain social distancing as much as possible.

I certify that I have not traveled in the last 14 days nor been exposed to anyone who has symptoms of COVID-19. I will inform Dr. Braun prior to any future appointments if this situation occurs.

If I or anyone in my household develops ANY potential symptoms of COVID-19, I will immediately inform Dr. Braun and reschedule my appointment
Signature *

Clear
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Registration Form - Braun Veterinary Housecalls