Mobile Veterinary Rehab & Acupuncture Services

New patient form


Owner Name:
Home Phone #                                            Cell phone #
 Emergency contact
Pet name:
Species:  Dog   Cat                                                Neutered/spayed:  Yes   No
Breed                                                                         Color
 Date of last Rabies vaccination:
  Referring/Regular veterinarian
 Referring Veterinary Clinic Name

Is this pet at working animal?  yes / no

Your pet's medical history: 

General Health:  

What would you say is the state of your pet's health?  good  /  fair  /  poor               

Has your pet had vomiting or diarrhea in past 72 hours?   yes / no                      If yes, for how long?

How is your pet's appetite?    poor  /  fair  /  good                    Is this normal for your pet?   yes / no

Diet:  What is pet eating and frequency?

Your pet's medications: 

List any supplements your pet takes: 

Do you use flea and tick medication on your pet?   yes / no

Does your pet receive heartworm preventative?  yes / no

other medications:

Previous illness/trauma:  Please list any illness and dates and any accidents, fractures, surgeries


Do you have other pets?   yes / no    How many other pets live in household?          

Reason for visit today: 

Authorization to perform veterinary acupuncture
I hereby authorize Dr. Kelly Avila to treat my pet _____________________ with veterinary medical acupuncture.  The nature and purpose of the procedure, possible alternative methods of treatment, the risks involved, and possibility of complications have been fully explained to me.  I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.  Further, I agree to pay for services rendered at the time of service.
 Signature of Person authorizing treatment:__________________________________
(Owner of animal or authorized agent)  please circle