Integrative Veterinary Medicine

Client Name

First NameLast Name

Contact Number

Please enter a valid phone number.

Email Address

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Species

Canine (Dog)Feline (Cat)

Animal Name

Breed

Colour

Age

Weight (kg)

Family Veterinarian(s) - Clinic Name

Veterinarian Name(s) (if applicable):

Specialist Veterinarian(s) - Clinic Name

Veterinarian Name(s) (if applicable):

Main Complaint(s):

Please describe the concerns you have with your animal, in bullet points.

Medical History (if applicable):

Date of last Rabies vaccination?

Date

Current Medication(s) - leave blank if not on any medications.

	Medication Name	Dose (mg)	Frequency	Duration
1)
2)
3)
4)
5)

Has Diagnostic Imaging related to the current concern been performed?

Has your animal had recent (within 12 months) labwork performed?

Please send or bring a printed copy of the labwork to the appointment with you.

Does your pet seek hot or cool environments to spend time in?:

Symptoms:

	Decreased	Normal (or N/A)	Increased
Food Intake
Water Intake
Urination habits
Vomiting
Stool
Cough
Activity Level
Sleep
Stiffness
Lameness
Voice

Informed Consent:

Veterinary Spinal Manipulation Therapy (VSMT): VSMT aka animal "chiropractic" involves a high speed, low force thrust specific to the anatomy of a given joint, which helps to restore normal movement of the region. Side effects are rare and may include transient muscle soreness at the adjustment site, lethargy or temporary worsening of symptoms. Response to chiropractic care can occur immediately or up to 72 hours following treatment. Results depend on age, severity of restricted motion and underlying issues.
*Veterinarians in Ontario legally cannot use the term chiropractic or chiropractor, only licensed human chiropractors can use these terms

Acupuncture: Acupuncture is one of the safest forms of medical treatment for animals when administered by a trained veterinarian. Side effects of acupuncture are rare and include bleeding, bruising, pneumothorax, soreness at the acupuncture site are possibilities. An animal's condition may seem worse for up to 48 hours after treatment. Other animals become lethargic or sleepy for 24 hours. These effects are an indication that physiological changes are developing, and they are most often followed by an improvement in the animal's condition.

I, blanks as the owner of the animal described above, consent to having Veterinary Spinal Manipulation Therapy (VSMT), medical acupuncture, and/or laser therapy performed on my animal by Dr. Hannah Pope.
I understand that there can be no guarantee as to the animal’s condition or reaction to or the outcome of any procedure/treatment undertaken. I declare that I voluntarily provide my informed consent.

Signature

Integrative Medicine - New Client Form