Quantum Qi Vet Client Registration Form

Quantum Qi Vet Client Registration Form

Please fill out your details to register as a new client.
Owner's Full Name*

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Pet's Name*
Species*
Breed
Age*
Health Concerns or Goals *
Energetic Pattern & Constitution.
Seeks cool surfacesPants easily or runs warmRestless or easily agitatedRed eyes, ears, or skinThirsty / drinks frequently
Seeks warmth / avoids coldLow energy or slow movingPrefers warm resting placesCold ears, paws, or bodyLoose stools / sensitive digestion
Tires easilyWeak or low staminaQuiet / less engagedPoor appetiteSoft voice or weak bark
Overweight or gains weight easilyGreasy coat or skin issuesChronic ear issuesLethargic / “heavy” demeanorLoose or sticky stools
Anxious or easily stressedReactive or irritableSighing, pacing, or restlessDigestive upset with stressTension in body
Dry coat or skinDull coat qualityThin body conditionBrittle nailsTends toward anxiety or sensitivity
List of current supplements, medications, or nutraceuticals *
Current Diet - Commercial food, list: brand, formula, amount, schedule OR home-prepared: ingredients, supplements, schedule*
This information helps us understand your pet’s internal balance from a TCVM perspective and tailor their care accordingly.
Previous Veterinary Clinics

Please enter any previous veterinary clinics we may contact for records.
Clinic Information:
To support a thoughtful and individualized healing process, we begin with a pre-visit energetic scan using Thera/BICOM technology. This gentle, non-invasive assessment allows us to enter your pet’s consultation with greater clarity and intention, and to prepare insights that will be reviewed together during your visit. A deposit ($111), along with a photo of your pet, is requested to initiate this process and support the time and care involved in preparing your pet’s assessment. This deposit will be applied toward your initial consultation.*

Cancelof
I understand and authorize Quantum Qi Vet to perform a pre-visit energetic scan for my pet and acknowledge that the required deposit initiates services and preparation and will be applied to my initial consultation. This preparation is completed in advance and may begin prior to scheduling a finalized appointment time.
Once complete, a member of our team will reach out to schedule an appointment.

Feel free to call us at 805-771-5066 or email at info@quantumqivet.com to expedite this process.
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Quantum Qi Vet Client Registration Form

Energetic Pattern & Constitution.

Previous Veterinary Clinics

Once complete, a member of our team will reach out to schedule an appointment.