Dongan Hills Veterinary Practice & Integrative Wellness Center

1. CLIENT INFORMATION

Owner Name(Required)

Co-Owner Name

Address

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Secondary Phone

Email Address

Preferred Contact Method

Call

Text

Email

2. PET INFORMATION

(Please complete for each pet. Additional pet? Please submit a separate form for each pet.)

Pet Name

Dog

Cat

Other

Breed

Color / Markings

Sex

Male

Female

Spayed / Neutered?

Yes

No

Date of Birth (or Age)

Weight (lbs)

Microchip #

3. PREVIOUS VETERINARY INFORMATION

Previous Veterinary Hospital

Phone

Date of Last Visit

MM slash DD slash YYYY

4. MEDICAL HISTORY

Current Medications (including dosage)

Allergies (food, environmental, medications)

Previous Surgeries / Major Illnesses

Current Medical Conditions

5. INTEGRATIVE WELLNESS SERVICES OF INTEREST

Integrative Wellness Services Of Interest

Acupuncture

Integrative Oncology

Ozone Therapy

Laser Therapy

Herbal Medicine

Nutritional Counseling

Vitamin C Therapy

Mistletoe Therapy

Diet Formulation

Other

6. WHAT ARE YOUR PRIMARY CONCERNS OR GOALS FOR YOUR PET?

What Are Your Primary Concerns Or Goals For Your Pet?

7. AUTHORIZATION

Authorization

I certify that the information provided is accurate to the best of my knowledge. I authorize Dongan Hills Veterinary Practice & Integrative Wellness Center to provide veterinary care for my pet. I understand that payment is due at the time services are rendered.

Signature

Date

MM slash DD slash YYYY

FOR OFFICE USE ONLY

Client ID

Patient ID

Staff Initials