Furmery First Visit Form
Welcome to Furmery! This initial intake form helps us get to know you better, and allows us to care foryour pet through integrative veterinary medicine—combining traditional and holistic approaches withcompassion, intention, and respect. May God bless your Fur-mily!
SECTION 1: Fur Parent Information
Email
*
example@example.com
Fur Parent Full Name
*
Mobile Phone Number
*
Please enter a valid phone number.
Format: 0000 000 0000.
Complete Address
*
Street Address
Street Address Line 2
Postal / Zip Code
City
State / Province
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Preferred Method of Contact
*
Email
Mobile Phone Call or Text Message
Viber
Social Media Handle
Other
Social Media Handle
SECTION 2: Pet Information
Pet Name
*
Species
*
Dog
Cat
Other
Breed
*
Gender
*
Male
Female
Spay/Neuter Status
*
Intact Male
Neutered Male
Intact Female
Spayed Female
Age
*
Birthday
-
Month
-
Day
Year
Date
SECTION 3: Lifestyle & Diet
Please describe your pet's current diet
*
Dry Food (aka Kibble)
Wet food (Canned)
Frozen fresh food
Raw Food
Homemade food
Other
Brand of Food
Frequency of feeding
Once a Day
Twice a Day
Other
SECTION 4: Medical History
List any current or past medical conditions/diagnoses. Write NA if not applicable.
*
List all current medications (Prescription and Over-the-Counter) and dosage. Write NA if not applicable.
*
List any current supplements (including vitamins, probiotics, fish oil, etc.) and dosage. Write NA if not applicable.
*
Does your pet have any known allergies (Food, environmental, medication)? If yes, please list them. Write NA if not applicable.
*
Details of your pet's last vaccination/booster? Ex: date, type (Please bring pet book on your visit)
SECTION 5: Traditional Chinese Veterinary Medicine (TCVM)
Have you done any TCVM Consultation or Insights?
*
Yes
No
If yes, please share what kind of TCVM treatments or insights your pet has had
SECTION 6: Your Pet's Personality & Preferences
Temperature Preference (Which does your pet gravitate towards?)
Prefers warm places (Sun, blankets, fireplace)
Prefers cool places (Tile floor, shade, panting frequently)
No strong preference
Thirst Level
Drinks a lot of water (Polydipsia)
Drinks a normal amount of water
Drinks very little water
Personality Type
Excitable, anxious, or high-strung (Wood/Fire)
Calm, easy-going, or sedentary (Earth/Metal)
Fearful, introverted, or lethargic (Water)
SECTION 7: Holistic History
Has your pet ever received any of the following holistic treatments? (Select all that apply)
*
Acupuncture
Herbal Medicine (Local, Chinese or Western)
Therapeutic Laser (Cold or Hot Laser)
Chiropractic/Osteopathy
Massage Therapy
Food Therapy
Other
NONE
SECTION 8: Spiritual Care
If you wish to, please share any prayer or intention requests for your pet's health and well-being.
Main reason for today's visit (Chief Complaint)
*
Regarding your pet's current state, how would you rate their overall vitality/energy level? (10 being the highest)
*
SECTION 9: Consent & Liability Agreement
I confirm that the information I provided is true and accurate to the best of my knowledge, and I authorize Furmery to examine and provide veterinary care to my pet. I understand that recommended examinations, diagnostics, treatments, and possible monitoring or hospitalization will be explained during the consultation. I acknowledge that no outcome is guaranteed, and understand that I may decline treatment at any time except in cases of medical emergency, where immediate care may be provided if deemed necessary by the veterinary team to protect my pet's life or welfare. I agree to release Furmery and its affiliates, owners, veterinarians, and staff from any and all liabilities.
Care Consent
*
I Agree to Both Holistic and Traditional Care
I Agree to Traditional Care only
To provide added learning and inspiration for pet-caretakers, I give permission for Furmery to share my pet's story, photos, videos, or testimonials for educational or informational purposes, including on social media, the website, and all other clinic materials. I understand that my pet's name may be mentioned, but no personal contact information will be shared. I acknowledge that shared content is not a guarantee of medical outcomes, may be reshared by others once published, and that while I may request future removal, complete removal from all platforms cannot be guaranteed. I agree to release Furmery and its affiliates, owners, veterinarians, and staff from liability related to the respectful and good-faith use of this content.
Photo & Story Permission
*
I Agree
Please do not include my Pet's photo nor story
Submit
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