New Patient FormPrior to your initial visit with Dr. Kim please complete the following form. We look forward to seeing you soon! Client Information Date MM DD YYYY Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### How did you hear about us? Pet's Information Name * Species * Breed * Sex * Date of Birth * Spayed/Neutered * Yes No Weight Regular Veterinarian Hospital Presenting Complaints & Problems What is/are the primary problem(s) you would like resolved? Date probem(s) began Origin (if known) Major Problem Associated With Morning Afternoon Evening Nighttime Spring Summer Winter Fall Other Concerns or Comments Medical History Vaccines up to date? Yes No Heartworm Prevention Type Flea and Tick Prevention Type Please list all previous and current medical problems and approximate dates of occurrence Food or Drug Allergies Current Medications or Supplements. List name, strength and dosage. Pet's Environment Pet's Origin Adoption Pet Store Breeder Stray Rescue Friend Lifestyle Please check all that apply Indoor Indoor/Outdoor No Exercise Intermittent/limited exercise Regular walks/exercise Diet Please check all that apply Canned Home cooked Dehydrated Dry Kibble Raw Diet Brand(s) Main Meat Source Please check all that apply Beef Lamb Duck Venison Chicken Turkey Fish Rabbit Other Eats Free Choice Yes No Pet's Behavior Personality Please check all that apply Agressive Dominant Laid back attitude Disciplined/obedient Greets strangers warmly Excited/Hyper-excitable Timid/Hides during exams Bites Friendly Quiet Loner/Aloof Noisy/Barking Urine leakage when greeting Fear biter Preferences Please check all that apply Warm areas Cool/Cold areas Hard surfaces Dry food over moist Moist food over dry Massage/brushing Lounging Laying in the sun Soft bedding Active Play Limited touch Company of others Phobias Please check all that apply None Thunder/Lightening Fireworks Noise People Other Other Phobias? Drinking habits Normal Increased Decreased Appetite Please check all that apply Normal Finicky Ravenous Decreased Increased Feces Please check all that apply Normal Watery Dry Mucous Strong smelling Loose Incontinent Bloody Straining No Smell Urination Please check all that apply Normal Bloody Wet Bedding Incontinent/Dribbling Straining Increased Vomiting Please check all that apply None Undigested food Frequent Sporadic Coprophagic (eats feces) Yes No Pica (eats grass, dirt, liter, rocks, etc) Yes No Sleep Please check all that apply Too much Vocalizes Too little Muscle jerking/dreaming Normal Stiffness/Pain Please check all that apply None Chronic Acute After laying down After walk Morning Evening Winter Summer Location of pain Sign Consent Form Do you consent to the following? * Informed Consent To Holistic Therapies I recognize that I am seeking a form of treatment for my pet that is likely to vary considerably from those offered at traditional veterinary practices . I hereby request and consent to the treatments and procedures within the scope of the practice of holistic veterinary medicine on my pet by Dr. Kim Lamb, Holistic Veterinary Care. I understand that the intent of these modalities is to re-establish balance within the body using innate healing potential. These forms of alternative medical practice include: 1) acupuncture, 2) chiropractic adjustments, 3) food therapy, 4) herbal medicine, 5) energy medicine and 6) others not listed here. I understand that herbals need to be administered according to written and/or oral instructions and will notify Dr. Lamb immediately of any unanticipated effects associated with the administration of herbal formulas. I understand that not all patients can or will benefit from one or more of these alternative medical approaches. I accept that the attending doctor may discuss, recommend, and/or prescribe other modes of care for my pet including referrals to general practitioners, boarded specialists, other alternative medical caregivers, conventional medical or surgical care. I authorize Dr. Kim Lamb to discuss my pet's medical history and treatment protocols with my family veterinarian as needed. I also understand and accept that Dr. Kim Lamb may decide not to offer suggested alternative medical care for my pet without further diagnostic testing or may decide not to offer such care because there is no apparent reason that it would benefit my pet. I further acknowledge that there is no guarantee as to the result of any treatment or supplement recommendation made by Dr. Lamb. I agree to hold Dr. Kim Lamb and Holistic Veterinary Care harmless in the event of unforeseen incidents while my animal(s) is/are under the care of Holistic Veterinary Care. I am the legal owner or representative of the legal owner of the animal(s) I present for diagnosis and treatment. I am over the age of 18 years. I understand Holistic Veterinary Care requires payment in full at the time services are rendered. Yes, I signed my name below and consent Please type your name here as a signature after reading the above * Thank you!
