New Patient Intake Form

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Guardian Name
Examples: Mx. They/them Ms. She/her Mr. He/him
Additional Guardian Name (if any)
Examples: Mx. They/them Ms. She/her Mr. He/him
How would you like to receive appointment and procedure reminders?
Include nicknames if used, eg. pet’s name is Macrame but is usually called Crema
Sex
Eg. 17 JAN 2021. Please estimate if actual date is unknown
Do you have pet health insurance?
Other pets in household or frequent close contact?
Please let us know the name of the veterinarian, friend or other pet-care professional who referred you, we’d love to say thanks!
Include date of onset if known
Include age at spay/neuter. Include vaccine reactions (if any)
Eg. 1. Metacam (meloxicam) 30kg dose once a day 2. Thyrotab (levothyroxine) 0.3mg every 12 hours 3. St. Francis Milk Thistle Tincture 1 dropperful with each meal If not currently given, please mark “NONE”
Vaccination details
Please email information to
Previous medical history and specialist referral summaries (if applicable)
Please have complete medical records from the past 2 years at all prior veterinary clinics and specialists emailed to
If diet was changed within past 3 months please include previous diet(s). Bring ingredient lists of foods and treats with you to the appointment or email to
Previous veterinary visit behaviour:
If your pet has had ANY fearful behaviour at veterinarians in the past, please contact us immediately about options for pre-visit anxiety medications and supplements so that we can ensure that they have a low-stress experience with us
Chart image is best viewed on desktop
Therapeutic modalities currently or previously used:
See chart below for fecal (poop) score images. Chart image is best viewed on desktop
Recent change in appetite, urination (pee) or defecation (poop) habits
Hospital Policy
A link to our hospital policy can also be found at the bottom of our home page.
Media Policy
A link to our media policy can also be found at the bottom of our home page.
TCVM Five Element CConstitutional hart

Fecal Score Chart