Herbal Consultation Intake Form

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Pet's Name*

Pet's Species*

DogCat

Pet's Breed or Mix

Pet's Sex*

Male NeuteredMale (not neutered)Female SpayedFemale (not spayed)

Pet's Date of Birth or Approximate Age*

Reason for Herbal Consultation:*

Medical history and/or pertinent information:*

Please list all medications and supplements (including preventive and over-the-counter) that your pet is currently taking:*

Please describe your pet's diet, including brand, form, frequency, etc.:*

Does your pet enjoy playing?*

YesNoSometimes/occasionally

Does your pet enjoy going on walks?*

YesNoSometimes/occasionally

How would you describe your pet's normal activity level?*

Very lethargic, only gets up to eat and go to the bathroomLazy or sleepy, but not lethargicLazy or sleepy, but easily engaged for playing or walkingAverageHyperactive

What is your pet's favorite thing to do?*

What is your pet's LEAST favorite thing to do?*

Please describe your pet's sleep patterns and quality:*

Please describe your pet's bowel movements and habits:*

Please describe your pet's urination habits:*

Please describe any vomiting habits that your pet has:*

Please describe your pet's personality:*

Please describe any behavioral or anxiety issues your pet experiences:

If there are other pets in the household, please describe their interactions:

Please describe how your pet interacts with children:

Does anyone in the household smoke indoors?*

YesNo

Does your pet get routine vaccinations and wellness exams?*

YesNoSometimes/occasionally

Do you use any lawn treatments or pesticides in your yard?*

What kind of water does your pet drink?*

Tap waterFiltered waterDistilled waterSpring/bottled water

Is there anything else you'd like me to know about your pet?*

Please initial here if I may post your pet's picture and medical history to social media:

I hereby authorize the Point Breeze Veterinary Clinic to examine and treat my pet using herbal medicine. I understand that this treatment is an alternative therapy and is not a "conventional" treatment.

Historical evidence and modern research indicate that the most commonly used herbs have an exceptional safety record. Confirmed cases of herb and drug interactions are rare. However, adverse events are possible. I understand that it is the pet owner's responsibility to fully disclose any medications currently in use, in addition to any herbal or nutritional supplements.

My signature below indicates that I have read this document in full and answered all questions truthfully and to the best of my ability. I hereby voluntarily consent to my pet receiving an herbal consultation and understand that I am free to discontinue this service at any time. I understand that the herbalist is not a doctor, but will consult on cases with veterinarians on staff as needed.

Signature*