Quantum Qi Vet Pet Intake Form

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Welcome to Quantum Qi Vet. We take a personalized, integrative approach to your pet’s care. This intake helps us understand your pet’s unique constitution prior to your visit.
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Owner Full Name* This field is required.
First Name
Last Name
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Preferred pronouns (optional)
He/him
They/them
She/her
Prefer to not answer
4
Owner Email Address* This field is required.
example@example.com
5
Owner Phone Number* This field is required.
Please enter a valid phone number.
6
Spouse/Partner/Additional Caregiver (optional)
First Name
Last Name
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How are they related to you? (optional)
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Spouse/Partner/Additional Caregiver's Phone Number (optional)
Please enter a valid phone number.
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Pet Name* This field is required.
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Species* This field is required.
Please Select
Please Select
Dog
Cat
Horse
Other
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Breed* This field is required.
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Age* This field is required.
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Sex* This field is required.
Please Select
Please Select
Male
Male neutered
Female
Female spayed
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What are your primary concerns or goals for your pet?* This field is required.
15
How is their energy level?* This field is required.
Tires easily
Low stamina
Quiet / less engaged
Normal energy
Active/engaged
Hyperactive/Excites easily
16
Temperature Preferences* This field is required.
Prefers to lay on the cool floor
Pants easily
Gets hot with any blankets over them
Restless or easily agitated
Seeks sunlight to lay in
Low energy or slow moving
Cold ears/paws/body
Loves to burrow under covers
Seems fairly neutral to me!
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Digestion & Body Condition* This field is required.
Loose stools
Sensitive digestion
Overweight / gains weight easily
Greasy coat or skin issues
Chronic ear issues
Normal
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Mood & Stress* This field is required.
Anxious or easily stressed
Reactive or irritable
Pacing / restless
Digestive upset with stress
Calm
19
Skin / Coat / Body* This field is required.
Dry or dull coat
Thin body condition
Brittle nails
Itchy
History of skin and/or ear infections
Dandruff or flaking skin
None
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Please describe your pet's diet (including treats)* This field is required.
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Please list any supplements or medications your pet is currently receiving* This field is required.
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Primary/Previous Veterinarian(s)Please let us know if you'd like us to reach out for their records
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Uploading a photo of your pet further supports our pre-visit energetic assessmentBy uploading a picture of your pet, you are allowing us to better prepare and customize your experience
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