Consultation Form - Holistic Pets

Pet Guardian Information

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Phone

Relationship to Pet:

Preferred Contact Method:

Text
Call
Email

Pet Information

Pet’s Name:

Breed:

Species:

Dog
Cat
Other

Pet's Date of Birth:

Sex:

Male
Female

Spayed/Neautered:

Yes
No

What age of Spay/Neuter:

Weight:

Color/Markings:

Upload picture of your pet:

Drag & Drop Files, Choose Files to Upload

A clear photo of your pet (sitting or standing, looking at the camera for diagnostic purposes.)

Photo of Problem Area (if applicable)

Drag & Drop Files, Choose Files to Upload

Veterinary History

Primary Veterinarian Name & Clinic:

Veterinary Clinic Phone Number:

Date of Last Visit:

Vaccination Status (List vaccines and dates, if known):

Current Medications & Supplements (Name, dosage, purpose):

Past Surgeries or Significant Medical Events:

Known Allergies or Sensitivities:

Diet & Lifestyle

Current Diet (Brand, type, frequency):

Treats/Snacks (type and frequency):

Water Source (tap, filtered, bottled, other):

Exercise Routine:

Daily Routine (including time spent alone):

Pet's Environment (Indoor/outdoor, other animals, stressors):

Concerns & Goals

Reason for Visit (Primary Concerns):

When did the issue(s) start?

Any known triggers or patterns?

Previous attempts to treat or manage the issue:

Has your pet seen any holistic/alternative practitioners before? (e.g., acupuncture, chiropractic, herbalist):

What are your goals for this consultation?

Holistic Health History (Optional but Helpful)

Has your pet ever received any of the following?

(Check all that apply):

1.

Acupuncture

2.

Chiropractic Care

Pets Pet pet’s

3.

Homeopathy

4.

Herbal Medicine

5.

Nutritional Therapy

6.

Energy Work / Reiki

7. Other (please specify):

Additional Information

Anything else we should know about your pet’s physical, emotional, or behavioral state?

Consent & Acknowledgement

1.

I understand that holistic pets consulting is complementary and does not replace emergency or conventional veterinary care when necessary.

2.

I understand recommendations may include natural remedies, dietary changes, or lifestyle adjustments.

RELEASE OF LIABILITY AND INFORMED CONSENT AGREEMENT

For Holistic Pets Consultation Services

This agreement is made between the undersigned Pet Guardian (“Client”) and Holistic Pets (“Practice”), including its veterinarians, employees, and affiliates.

1. Purpose of Services

a.

I understand that the consultation provided is based on holistic, integrative, or complementary veterinary approaches which may include—but are not limited to—nutritional counseling, herbal therapies, and other natural modalities. These services are not intended to replace conventional veterinary care, emergency treatment, or diagnostics when necessary.

2. Acknowledgement of Scope and Limitations

a.

I understand that holistic therapies are often used in conjunction with, and not in place of, conventional veterinary medicine.

b.

I acknowledge that results may vary based on each individual animal and that no guarantees or assurances have been made regarding the outcome of any recommended treatment.

c.

I understand that certain holistic recommendations may not be recognized by conventional veterinary organizations or covered by pet insurance policies.

3. Disclosure of Medical History

a.

I affirm that I have provided a full and accurate history of my pet’s health, including current medications, supplements, treatments, and known medical conditions. I understand that failure to disclose relevant health history may affect the care and recommendations provided.

4. Release of Liability

In consideration for receiving holistic consulting services, I hereby voluntarily agree to assume all risks and responsibility for any adverse effects that may result. I, for myself and my representatives, heirs, and assigns, do hereby:

a.

Release and hold harmless Holistic Pets, its veterinarians, staff, agents, and affiliates from any and all liability, claims, demands, actions, or causes of action, arising out of or related to any loss, damage, or injury, including death, that may be sustained as a result of care or services provided.

b.

Agree not to initiate any legal proceedings against Holistic Pets with respect to these services.

5. Consent to Treatment

a.

I hereby consent to the holistic consultation and to the recommended treatment options as discussed with me. I understand that I may withdraw consent at any time and that I am encouraged to ask questions and seek clarification.

Pet Guardian Name:

First

Last

Pet Guardian Signature

Clear Signature

Date