New Patient Intake Form - Dr Dee’s Veterinary Acupuncture

Owner's Name

Phone number *

Email Address

Patient's Name *

Sex *

DOB

Species *

Breed

Diet

Preventatives (flea, tick)

Supplements

Medications

HistoryPlease forward any relevant medical history, imaging or blood results to drdeesivm@gmail.com

Reason for visit *

What are your goals for your pet's treatment with Acupuncture?

Does your pet prefer warm or cool places, or neither?

Please share any additional information you think is important about your pet

Which of these best describes your pet? (They may have characteristics of more than one)Dominant, aggressive, competitive, athletic, confident, fearless, can be irritable or anger easilyFriendly, playful, sensitive, noisy/talkative, wants to be petted, center of attention, strong body, can be hyperactive or have anxietyLaid back, easy going, friendly, slow moving, sweet, tolerant, nuturing, worries, can overeat/prone to obesityAloof, independent, likes order and rules, quiet, upset with change, can become sad/depressedTimid, shy, fearful, nervous, fear-biter, likes to hide, careful and curious

Owner *

Date *

Consent to Proceed with Acupuncture Form