Integrative Medicine: Intake Form

Integrative Medicine Intake Form

Please complete this form at least 48 hours prior to your pet's first Integrative Medicine appointment.
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
General Information
Please Note

Dr. Xie is currently on maternity leave and will return on 7/24/26. You are still welcome to submit this form during this time; however, responses and case reviews will begin once Dr. Xie returns. If you need additional assistance or care for you pet please give us a call at 215-563-8387. We appreciate your patience and look forward to connecting with you soon!
Owner Name

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

Primary Complaint(s)
What is/are the primary reason(s) you are bringing your pet into the Integrative Medicine?
Reason 1
Reason 2
Reason 3
What are your goals for your pet?
Reason 1: {typeA}
How long has the problem(s) been going on and has there been any progression of symptoms?
What treatments (medications, supplements, procedures, surgeries) has your pet received for these concern(s)?
What was the response to treatment?
Reason 2: {reason2}
How long has the problem(s) been going on and has there been any progression of symptoms?
What treatments (medications, supplements, procedures, surgeries) has your pet received for these concern(s)?
What was the response to treatment?
Reason 3: {reason1112}
How long has the problem(s) been going on and has there been any progression of symptoms?
What treatments (medications, supplements, procedures, surgeries) has your pet received for these concern(s)?
What was the response to treatment?

Behavior at the Vet
What is your pet's typical behavior at the vet? Are they anxious or aggressive? Are they willing to take treats?
Does your pet receive pre-visit pharmaceuticals before vet visits (e.g., trazodone, gabapentin)? If so, please provide drug name and dosage instructions.
Please list any specific treats that your pet likes.
Can we offer treats to your pet during treatment sessions?
Please list any foods that your pet can't eat due to specific circumstances (e.g. allergies).
If no food restrictions, please write N/A.
Should be Empty:

Rows	Yes	Where?	When?
Bloodwork
Radiographs (x-rays) of the spine or limbs
Radiographs (x-rays) of the chest or abdomen
Radiographs (x-rays) of the skull
Fine-Needle Aspirate and Cytology
BIopsy/Histopathology
Abdominal Ultrasound
CT or MRI

Integrative Medicine Intake Form