Traditional Chinese Veterinary Medicine
Nutrition and Supplements
Patient History Form
Client Acceptance Form
Veterinary Referral Form
The below form is to be filled out by the person responsible for the care of the cat or dog.
Indicates required field
Co-Guardian Name (if applicable)
Emergency Contact Name
Emergency Contact Phone Number
How Did You Hear About Us?
Referral (Please list the person we may thank below)
Other (Please explain below)
Name or Explanation
Because many of our clients choose to maintain relationships with their allopathic vets for complementary or emergency care, it is helpful for us to have contact information when coordinating the care of your pet. Please list any other veterinary doctors or facilities with whom you may be working.
Veterinarian/Clinic Phone Number
May we contact your veterinarian to have records on your pet sent to Holistic Veterinary Care?
I would prefer not
I will contact my vet for the record transfer
If it is determined that your pet should receive care from another practitioner, it may be necessary that we share information with them. The Kentucky Board of Veterinary Medical Examiners requires veterinary hospitals to have written permission before releasing ANY medical information. If you do not wish to have information on your pets released without being contacted first, you may indicate so below. Be aware that if we receive a request for information, you will be required to provide Holistic Veterinary Care written permission before information can be released.
Release of Information
I authorize Holistic Veterinary Care to release information including diagnosis, records, and lab work of my pet(s) to the following: Any Veterinary Hospital, Referral Specialists, Emergency Hospitals, Boarding Facility, Grooming Facility.
I decline Holistic Veterinary Care to release any information on my pets.
THIS PERMISSION TO RELEASE INFORMATION WILL REMAIN IN EFFECT UNTIL TERMINATED BY ME IN WRITING
Please be aware of the following policies:
Whenever possible, we appreciate the courtesy of a 24 hour notice if you are unable to keep a scheduled appointment.
Holistic Veterinary Care is not an emergency facility. Please seek emergency care as needed with the reassurance that we can follow up holistically when the acute situation has been stabilized.
Payment is due at the time of services unless prior arrangements have been made.
By submitting this form, I confirm that I have read and understand the above policies, and understand what is expected from me by seeking treatment for my pet(s) at Holistic Veterinary Care.
Copyright 2017 Holistic Veterinary Care