Urban Vet Care - Acupuncture Registration Form

Acupuncture Intake Form

NOTE: This form should only be filled out by clients seeking acupuncture therapy with Dr. Lauren Ungar, DVM.
Is Urban Vet Care the Primary Veterinarian for your pet(s)*

YesNo
Owner's Email*
example@example.com
Owner's Name*

First NameLast Name
Spouse/Partner

First NameLast Name
Owner's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Employer
Work Phone Number

Area CodePhone Number
Emergency Contact*

First NameLast Name
Emergency Contact's Phone Number*

Area CodePhone Number
Pet's Name*
Species *

DogCat
Date of Birth/Age*
Breed & Color*
Sex*

MaleFemaleMale NeuteredFemale Spayed
Weight*
Lbs
Primary Reason(s) for Acupuncture Consultation*
What do you feed your pet? *
Please list brand, amount, frequency, flavor, canned/dry/both and any treats given your pet.
Please list any previous or health issues for your pet.*
N/A if not applicable
Please select all UP-TO-DATE vaccinations for your pet.

RabiesFeline FeLVCanine BordetellaFeline FVRCPCanine DAPPCanine Leptospirosis
Please list all medications and supplements your pet is receiving (please include heartworm and flea preventative medications).*
N/A if not applicable

Please fill out the survey below.*

	Normal	Increased	Decreased
Activity Level
Sleep
Food Intake
Water Intake
Urination
Stiffness
Vocalization
Panting

If you marked any areas as increased or decreased, please explain
Is your pet coughing, sneezing, vomiting, or has abnormal stool? If yes, please explain.*
Any belching or gas? If yes, please explain.*
Which of these BEST describes your pet? (He/she may have characteristics of more than one)*

WOOD CONSTITUTION: dominant, aggressive, competitive, athletic, confident, fearless, can be irritable or anger easilyFIRE CONSTITUTION: friendly, playful, sensitive, noisy/talkative, wants to be petted, center of attention, strong body, can be hyperactive or have anxietyEARTH CONSTITUTION: laid back, easy going, friendly, slow moving, sweet, tolerant, nurturing, worries, can overeat/prone to obesityMETAL CONSTITUTION: aloof, independent, likes order and rules, quiet, upset with change, can become sad/depressedWATER CONSTITUTION: timid, shy, fearful, nervous, fear-biter, likes to hide, careful and curious
Please select all of the common ailments your pet is suffering from:

DiarrheaVomitingConstipationImmune DisorderChronic Urinary Tract DiseasesChronic Dermatologic ConditionsBehavioral ProblemsSeizuresBack/Neck PainOsteoarthritisLamenessChronic Respiratory ProblemsGeriatric or muscle weaknessPost operative painFeverParalysis/Paresis
Do you already have a scheduled acupuncture consultation?*

YesNoI submitted an online appointment request
Appointment Date & Time*

MonthDayYear
DateHourMinutesAM/PM Option
Previous Veterinarian
How did you hear about Acupuncture at Urban Vet Care?*

Referral from Urban Vet Care DoctorReferral from Outside VeterinarianOther ReferralGoogle/Internet SearchVeterinarians.com or LocalVets.comYelp.comFacebook.comStreet FairLocal NewspaperRadio/TVOther
Please let us know who we may thank for referring you to Urban Vet Care Acupuncture.
Please list the names and types of other animals that you own.
Do we have permission to use photos of your pet(s) on Facebook, Twitter, Instagram and our website?*

YesNo
I understand that I am responsible for services and for all charges incurred in the care of the my pet. I further understand that these charges will be paid at time of services and that a deposit may be required.*

First NameLast Name
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