New Patient Form

New Patient Form
Client Information
Name*

First NameLast Name
Pronouns
Second Person in Household (if applicable)

First NameLast Name
Pronouns
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Additional Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
Patient Information
Pet's Name
Species
Breed
Color/Pattern
Date of Birth
or approximate age
Weight (can be approximate)
Sex

MaleFemaleNeutered MaleSpayed Female
Where did you get your pet from and at what age?
Primary Care Veterinarian *
Hospital/Clinic Name and Dr
Does your pet have insurance? If yes, please provide name of insurance company.
Has your pet received acupuncture before? If so, where did they receive
Pet Disposition

FriendlyAloofTimidFearfulLaid BackFear biterAggressiveDominant
Has your pet ever bitten or tried to bite anyone?

YesNo
If Yes, please explain
Temperature Preference

Loves to lay in the sun/warm placesLoves to lay in cool spaces/surfacesGoes between cool and warm surface/spaces
Medical History
Past and Current Medical Conditions/Diagnosis
Please note if current or resolved
Any history of trauma or surgeries in the past? If so, please list approx date of occurance and explain.
History of cancer? If so, please explain
Current Medications, Supplements, Vitamins, etc
Name, Strength, how often administered
Does your pet have a history or seizures?
Has your pet shown sensitivity towards medication or supplements in the past?

YesNo
Current Diet
Allergies
Appetite

RavenousFinickyIncreasedDecreasedNormal
Water Intake

NormalIncreasedDecreased
Feces

FormedLoose, but has formLiquidDryHard
Urination

NormalIncreasedDecreasedIncontinence
Sleep Habits

NormalIncreased sleepingRestless sleepingPacing
Does your pet pant often?
Pain/Stiffness

LimpingPain/Stiffness throughout the dayPain/Stiffness worse after restPain/Stiffness worse after activityNone
If your pet is limping, how long have they been limping?
What are the top 3 concerns you would like to address?
Anything else you would like Dr. Kristen to be aware of?
Does your pet have a instagram account? If so, please provide their handle. We would love to follow them!
Please upload recent medical records or email them to us at nyvetacupuncture@gmail.com. If you would prefer us to reach out to your primary care veterinarian(s) to ask, please select that option below.*

Yes, please contact my primary care veterinarian for a copy of medical recordsI will upload/email my pet’s medical records
Please upload any medical records that may be helpful as well as any recent bloodwork. Alternatively they can be emailed to nyvetacupuncture@gmail.com
File Upload

Cancelof
By signing below you acknowledge and accept our cancellation policy:

We understand that life can be unpredictable, especially in New York. However, out of respect for the practitioner and for wait-listed patients, we honor a firm 24 hour cancellation policy. Please understand, when we reserve a block of time especially for you, we are turning away other guests to keep the slot secured. Please reschedule or cancel at least 24 hours before the beginning of your appointment or you will be charged a cancellation fee of 50% of the cost of services. When booking an appointment, you are agreeing to our cancellation fees should you need to cancel or reschedule within 24 hours of your appointment time, regardless of the reason for cancellation.
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New Patient Form

Client Information

Patient Information

Medical History

Please upload any medical records that may be helpful as well as any recent bloodwork. Alternatively they can be emailed to nyvetacupuncture@gmail.com