Mobile Veterinary Rehab & Acupuncture Services
New patient form
Home Phone #
Cell phone #
Species: Dog Cat
Neutered/spayed: Yes No
Date of last Rabies vaccination:
Referring Veterinary Clinic Name
Is this pet at
working animal? yes / no
Your pet's medical
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
What is pet eating and frequency?
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
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
Authorization to perform veterinary acupuncture
I hereby authorize Dr. Kelly Avila to treat my pet _____________________ with veterinary medical acupuncture. The
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