New Patient Form

It is our mission to help achieve optimal healing and quality of life for your pet by customizing a treatment plan specific to them. Due to the nature of our practice, New Patient Consultations are 60-90 minutes and $185.00 (plus tax) per pet. Treatments and diagnostic testing such as acupuncture, chiropractic adjustments, nutritional supplements, herbals, and blood tests will have additional fees. When we call to schedule your pet(s), we will be taking a deposit to hold your appointment. Since our consultation appointments are scheduled for an hour or more, the deposit will be the cost of the initial consultation. If you cancel within 48 hours or fail to arrive, your deposit will not be refunded.

New Patient Form

This form is to be filled out by the person responsible for the care of the pet coming to Holistic Veterinary Care.

Patient Information

* Indicates required field

Patient's Name *

Choose One *

Female Male Female - Spayed Male - Neutered

Breed *

Color and Markings *

Age or Date of Birth *

Because diet is so important to the health of an animal, please list all foods and treats that your pet has eaten in the last 2 months. Include all commercially prepared and any home cooked or people food that your pet may receive. Also, list any treats, bones, etc. that your pet may consume.

Foods/Treats *

List all medications and supplements that your pet has taken in the past 2 months. Include those prescribed by your veterinarian, and those that you purchased on your own. This should include any injections adminstered by your veterinarian, not including vaccinations. Be as specific as possible.

Medications/Supplements *

In the following area, please list all vaccines that your pet has received in the past year. Be as specific as possible and include dates administered.

Vaccinations *

Describe your pets daily activity level. For example: How many hours are spent engaged in active play? Do they enjoy a daily walk, and for how long? Do they tire after a few minutes or a few hours after being active?

Activity Level *

TCVM History

In the following area, describe your pet's traits. For example: Is your pet shy or outgoing? Friendly to other pets/people? Any fears or anxieties? Is he/she bonded to a particular family member, or just loves everyone? Include anything that comes to mind.

Patient's Traits *

My Pet Prefers *

Warmth (Likes to lay in the sun/under blankets) Cold (Likes to lay on cool floors/gets hot easily) No preference

Any recent vomiting or diarrhea? *

Any abnormal drinking/urinary habits? *

Below, please describe the reason for your appointment request. List the primary concern that you have first, then any other concerns you may have no matter how minor you think they are. Any change, even small, may be important.

Reason(s) for Appointment Request *

Is there anything else we should know? *

Guardian Information

Guardian's Name *

First

Last

Phone Number *

Choose One *

Mobile Home

Email *

Co-Guardian's Name *

First

Last

Phone Number *

Choose One *

Mobile Home

Date *

Guardian Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

How Did You Hear About Us? *

Web Search Facebook 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 ALL other veterinary doctors or facilities with whom you may be working.

Veterinarian/Clinic Name(s) *

Veterinarian/Clinic Phone Number(s) *

May we contact your veterinarian to have records on your pet sent to Holistic Veterinary Care? *

Yes No 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

We are honored that you have chosen to trust us with the care of your animal. As you are likely aware, our practice is rather unique: We offer treatment modalities that include acupuncture, chiropractic, herbal medications, supplements, cold laser therapy, and nutritional counseling. We emphasize these forms of treatment because we believe they provide the most effective way to deal with a wide variety of health problems that animals face by providing the body with the tools it needs to heal itself rather than masking the symptoms of disease.

By practicing holistic medicine, we will use the most appropriate modality of medicine your animal needs at that specific point in time. We believe that these alternative therapies or a combination thereof can be used to treat the same broad range of problems that are conventionally treated with drugs. This is a very successful approach. Yet if we determine that your animal would benefit from pharmaceuticals, surgery, or any other form of conventional treatment, we will not hesitate to recommend such methods. After all there is no “right” or “wrong” medicine; the key is finding how to best support your animal’s long-term health with success.

Holistic medicine includes many different modalities to encourage healing. As with any treatment, each pet may respond differently and results may vary between patients.

It is important, as we start working together, that you understand we are going to use alternative medicine with a holistic approach in the treatment of your animal. We strongly advise that you maintain a relationship with a traditional veterinarian; we are a complimentary practice and do not perform any procedure that involves sedation or anesthesia. If we believe that for the well-being of your pet you should receive care from another practitioner or would benefit from further diagnostics (such as radiographs or ultrasound), we will refer you for this care rather than provide it ourselves.

We are committed to meeting your expectations of complete holistic health for your pet. In turn, we request your commitment to our treatment plan. Holistic care is most effective when the pet owner is an active participant in the healing process. The best way to contribute is to keep a close eye on the moods, behaviors and movements of your pet in the days and weeks following an appointment. Many pet owners find it helpful to keep a notepad or journal close by so they can record observations and rate symptoms and improvements. Holistic treatments gradually bring the animal’s body back into balance, so even subtle changes – positive or negative – can be meaningful to us.

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 the above policies and explanation concerning the type of care my animal will be receiving and I agree this is what I want for my animal, and understand what is expected from me by seeking treatment for my pet at Holistic Veterinary Care.

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New Patient Form

Patient Information

TCVM History

Guardian Information

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New Clients

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New Patient Form

Patient Information

TCVM History

Guardian Information

Home﻿﻿

About Us

Services

New Clients

Contact Us

Home