Acupuncture Inquiry Form

Acupuncture Inquiry Form

Please fill out the following form if you are interested in scheduling acupuncture therapy for your pet. Acupuncture appointments are scheduled based on practitioner availability and the appropriateness of this therapy for your pet’s condition. Submitting this form does not guarantee that your pet will be scheduled for acupuncture. Once submitted, we will reach out to you by email with additional information about acupuncture, our fee structure, and an invitation to schedule if this therapy is appropriate for your pet.
Name

First NameLast Name
Pronouns

Other (please write your pronouns here)
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Partner's Name (if applicable)

First NameLast Name
Partner's Pronouns (if applicable)

Other (please write your pronouns here)
Partner's Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Are you a new client at St. Francis Animal Hospital? **Please note that we are only accepting new clients who have been referred by current clients.**
If you are not a current/former client: Who referred you to St. Francis Animal Hospital?

Referred by:
Who referred you to St. Francis Animal Hospital?
Pet Information
Pet's Name
Pet's Date of Birth or Age (please note if this is an estimate)
Species

Other
Breed
Color
Sex
Is your pet spayed or neutered?
What is your pet's weight?
What is your pet's primary diet?
Please include brand and amount fed, i.e. Purina Sensitive Skin and Stomach, 1/2 cup twice a day
Does your pet have medical records at another veterinary clinic? If so, please list the clinic(s) so we can contact them for your pet's records.
Upload previous medical records

If you have your pet's previous medical records, vaccine history, or other pertinent medical information, please upload those files here.
Upload file(s) here

Cancelof
Why are you seeking acupuncture therapy? What are your goals for therapy?
Does your pet have any fear, anxiety, or aggression at the veterinary clinic? Do you think they will tolerate acupuncture therapy well?
What is your familiarity level with acupuncture (for pets and/or yourself)?
Clinic Policies
Please note that you must be present at your pet/pets' first visit to our clinic. Pets should not be brought in for their first exam to establish care by a petsitter, a minor, or anyone other than a primary owner.

Payment is due at the time services are rendered. We do not offer payment plans, but we do offer the following options for payment:
- Cash
- Check
- Credit Card (Visa, Mastercard, American Express, and Discover)
- Apple Pay
- Google Pay
- Care Credit
- ScratchPay
Please confirm below that you have read and understand our policies regarding being present at your first visit as a new client and regarding payment.
How did you hear about St. Francis Integrative Services? (choose all that apply)

Other (please specify)
Who referred you?
Should be Empty:

Acupuncture Inquiry Form

Pet Information

Upload previous medical records

Clinic Policies