Caregiver's Name *

First

Last

Caregiver's Address

Address Line 1

Address Line 2

City

State

Zip Code

Caregiver's Phone Number *

Caregiver's Email Address *

Patient's Name *

Patient's Age and/or Date of Birth *

Species *

Dog
Cat

Patient's Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

Diet *

Treats

Prevention (heartworm/fleas/ticks) *

Medication(s) *

Supplement(s)

Please describe your pet’s general history, including how long you’ve had them, if they were adopted or purchased, if there have been any significant changes in the pet’s life, if there have been any significant medical issues in the past, etc: *

Please describe your most significant reasons for consulting a veterinary acupuncturist and your main concern for your pet. Please include how long this concern has been going on: *

For the following Symptoms or Clinical Signs, please indicate whether you think it is. *

If other, please explain:

Voice (barking or meowing): *

Activity Level: *

Sleep: *

Food Intake: *

Water Intake: *

Stool (defecation): *

Urination: *

Vomiting: *

Cough: *

Stiffness (in joints): *

How would you describe the following in your pet's activity? *

Prefers to lay in the shade and on cool surfaces
Prefers to lay in the sun and on warm surfaces

How would you describe the following in your pet's personality? *

Is hyperactive, outgoing and confident
Is quiet, timid, and less confident

How would you describe the following in your pet appetite? *

Has a ravenous appetite
Is a picky/finicky eater

How would you describe the following in your pet's stool? *

Has feces that is dry
Has feces that is wet

Please also describe if any loose stool, diarrhea, blood, odor, etc:

How would you describe the following in your pet's urine? *

Has short streams of urine
Has long streams of urine

Please also describe any odor, blood, or leakage:

Please make any additional comments here:

Please read the following to give informed consent for our policies and procedures:

ALTERNATIVE TREATMENTS

I understand that Alma Vet Connection offers both traditional/conventional veterinary care AND alternative care modalities. These modalities may include:

Acupuncture
Herbal Medications
Ozone Therapy
Tui na Massage Techniques
Food Therapy
Homeopathic Remedies
Veterinary Orthopedic Manipulation
Ultraviolet Blood Irradiation
Pulsed Electro Magnetic Frequencies

I understand that the safety and/or effectiveness of some alternative modalities may not be well-established and/or are deemed “experimental” according to the American Veterinary Medical Association and/or the U.S. Food and Drug Administration. I also understand that, although rare, the potential for adverse reactions to some of these treatments exists.

I agree that Alma Vet Connection has explained, in sufficient detail to understand and with the opportunity to ask questions, the alternative treatments above so that I can make an educated decision on their use for my pet. I also realize that I have the option to do nothing if I so choose.

OFF LABEL USAGE

I acknowledge that, due to manufacturer supply limitations and FDA regulations, it is a common veterinary practice that some medications prescribed or administered may be compounded or used “off label.”

PAYMENT

I accept ALL financial responsibility and understand that all professional fees are due at the time of services. I understand that additional charges may apply when applicable, such as a missed appointment fee or an emergency work-in fee.

EMERGENCY CARE

In the event of an emergency, if I am not present, I understand that every attempt will be made to contact me. I hereby give permission for any reasonable treatments needed to stabilize my pet to be done or given in the event of said emergency, unless specifically discussed otherwise, such as during admission to the hospital for anesthesia/surgery.

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