Full Name
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First Name
Last Name
Address
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Street Address
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City
State
Zip Code
Phone
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Area Code
Phone Number
Alternate Phone
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Area Code
Phone Number
E-mail
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Pet's Name
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Species
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Canine
Feline
Lapine
Equine
Bovine
Camilid
Caprine
Cavies
Cervidae
Murine
Ovine
Piscine
Porcine
Other
Sex
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Neutered Male
Spayed Female
Male Not Neutered
Female Not Spayed
Pet's Breed
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Pet's Color
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Date of Birth
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Month
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Day
Year
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How Long have you had your pet?
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Weight (in lbs)
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What Service are you Interested in?
Consultation for Traditional Chinese Veterinary Medicine
Chinese herbal Consultation
Tui-na consultation
Laser consultation
Integrative
In-home euthanasia
In-home hospice consultation
Geriatric and palliative care consultation
Travel / Health certificate
Dog Sporting Event- treatments
Veterinary Medical Manipulation
Other (please describe in last text box)
Please tell us in one brief sentence your reason for seeking Chinese Medicine for your pet
What days of the week and/or times of day are preferred?
What type of appointment is preferred?
In Clinic
What is the name of your primary veterinarian and/or veterinary hospital?
How did you hear about Dr. Bross and Joy-Chi Veterinary Acupuncture?
If a friend referred you, please list their name so we may thank them
Any Other Information you would like to share?
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