New Patient FormClient InformationDate Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email Phone (Home)Phone (Cell)How did you hear about us?Pet's InformationNameSpeciesBreedDOBSexSpayed/ NeuteredYesNoWeightRegular VeterinarianHospital NamePresenting Complaints & ProblemsWhat is/are the primary problem(s) you would like resolved?Date problem(s) began:Origin (if known):Major problem associated with:(please check all that apply) Morning Afternoon Evening Nighttime Spring Summer Winter FallOther Concerns or Comments:Medical HistoryVaccines up to date?YesNoHeartworm 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 SupplementsList name, strength, and dosage:Pet's EnvironmentPet’s Origin:AdoptionPet StoreBreederStrayRescueFriendLifestyle:(please check all that apply) Indoor Indoor/outdoor No exercise Intermittent/limited exercise Regular walks/exerciseDiet:(please check all that apply) Canned Home cooked Dehydrated Dry kibble RawDiet Brand(s):Main Meat Source: Beef Lamb Duck Venison Chicken Turkey Fish Rabbit Other(please check all that apply)Eats Free ChoiceYesNoPet's BehaviorPersonality:(please check all that apply) Aggressive 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 biterPreferences:(please check all that apply) Warm areas Cool/cold areas Hard surfaces Dry food over moist Massage/brushing Lounging Laying in the sun Soft bedding Active play Moist food over dry Limited touch Company of othersPhobias:(please check all that apply) None Thunder/ lightning Fireworks Noise People OtherOther Phobias?Drinking Habits:(please check all that apply) Normal Increased DecreasedAppetite:(please check all that apply) Normal Finicky Ravenous Decreased IncreasedFeces:(please check all that apply) Normal Watery Dry Mucous Strong smelling Loose Incontinent Bloody Straining No smellUrination:(please check all that apply) Normal Bloody Wet bedding Incontinent/ dribbling Straining IncreasedVomiting: None Undigested Food Frequent SporadicCoprophagic (eats feces):NoYesPica (eats grass, dirt, litter, rocks, etc.):NoYesSleep:(please check all that apply) Too much Vocalizes Too little Muscle Jerking/ dreaming NormalStiffness/Pain:(please check all that apply) None Chronic Evening Winter After walk Acute Morning After lying down SummerLocation Of Pain:Sign Consent FormInformed 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.Please sign your name here (type your name):Do you consent to the above? ** Yes I signed my name and consent.Verification For more information or to schedule an appointment, please don't hesitate to call us today at (603) 667-6800!