New Patient Intake & Consent Form

New Patient Intake & Consent Form
Owner/Agent Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Pet Name*
Species*
Primary Veterinarian (The practice name or the name of the veterinarian is fine)
Sex*
Spayed/Neutered*
If intact female, is she (could she be) pregnant? *
Breed
Color
Age*
Weight (lbs)*
Date of Last Rabies Vaccination*
Medical History
Surgeries & Hospitalizations (Please list any past surgical procedures and/or hospitalizations)
Medications & Supplements (Please list any current medications and/or supplements)
History of Presenting Complaint
Chief Complaint (Briefly describe the current complaint)*
What makes is better or worse?
How long has your pet been ill?
Have you noticed a change in mood, attitude or awareness ? If yes, please describe.
Does your pet prefer to be warm or cold ?
Does your pet pant more than normal ?
Urination

Urinating in the house or outside the litter boxDribbles urine throughout the dayDribbles urine in bed overnightDifficultly urinatingUrine has changed colorUrine has a strange smell
Defecation

Defecating in the house or outside the litter boxDifficultly DefecatingDiarrheaConstipation
Have you noticed a change in your pet's bark or meow ?
Have you had a change in your home ?

Recent MoveLoss of family member or another petNew person or animal to the household
Is this issue seasonal ?

NoYes, SpringYes, SummerYes, FallYes, Winter
On a scale of 1 to 5 (5 being most severe), Rate the severity of your pet's condition
Current Diet
TCVM Assessment

(Please check all boxes that apply)
Fire Element Personality Traits

LivelyCommunicativeVery Friendly with everyone including strangersLoves to be groomedLoves to be in the show ringDiva
Fire Element Imbalances

InsomniaSeparation AnxietyRestlessAlways hotHeart Disease - congenital defect, murmur, arrhythmia, ect
Earth Element Personality Traits

Laid back, lazySociable, Friendly with other animals and peopleSolid - Chubby, Well muscled, Big bonedLoyalFood MotivatedMotherly, Cares for othersCan be stubborn if they think you are being unfair
Earth Element Imbalances

DiarrheaConstipationLoss of ApetiteVomitingGum DiseaseWeak MusclesOver eater - ObeseWorried
Metal Element Personality Traits

Likes to have a daily routineObeys the rulesAloofDoes not like changeDisciplined AttitudeVery Trainable
Metal Element Imbalances

Breathing disorderAllergiesCoughDry SkinImmune mediated disease
Water Element Personality Traits

CarefulCuriousDoes not like strangersAfraid of new things/loud noisesSubmissive to other animals
Water Element Imbalances

Panic attacksRear limb weaknessArthritisBack painUrinary problemsDeafnessAbnormal growth - angular limb deformity, small, frailReproductive problems in breeding animals
Wood Element Personality Traits

AssertiveConfidentStrongImpulsiveAthleticAlpha in the pack
Wood Element Imbalances

Tendon and/or ligament problemsLive diseaseEye problemsAngry/AggressiveEar disease/InfectionNail problems
Acknowledgments & Signature
I consent to the examination of this pet by staff veterinarians and chiropractors at Holistic Veterinary House Calls. I also agree that after consultation with me, the doctors may prescribe medication for, treat, sedate, perform acupuncture, perform chiropractic adjustments, and/or perform laser therapy on my pet.*

Yes
Given the sometimes unpredictable nature of house calI visits I understand that appointment times are approximate and that flexibility is important. I also understand that in-home euthanasia service requests take priority and I understand that due the often urgent nature of in-home euthanasia requests, sometimes TCVM appointment dates and/or times may need to be adjusted or rescheduled unexpectedly.*

Yes, I have carefully read and fully understand the foregoing provisions
I understand that some risks always exist with any treatment and that I am encouraged to discuss any concerns with the attending veterinarian before the procedure is initiated.*

Yes, I have carefully read and fully understand the foregoing provisions
I understand the fees and understand that I am encouraged to discuss all fees related to such care before services are rendered including during my pet's ongoing medical treatment. I understand payment is due at the time of service or when electronic invoice has been emailed. I understand that late payment(s) may be sent to collections after 90 days.*

Yes, I have carefully read and fully understand the foregoing provisions
I consent to sharing my pet's records when a referral is necessary.*

Yes
I understand that after submitting the new patient intake form I must contact (if I haven't already) Holistic Veterinary House Calls to schedule an appointment (941.320.8684).*

Yes
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Patient Intake & Consent Form

Medical History

History of Presenting Complaint

TCVM Assessment

Acknowledgments & Signature