Please complete the following ACUPUNCTURE ADMISSION FORM in its entirety and click submit at the bottom. If bringing in more than one pet, please complete one form for EACH pet. Thank you.

Who is bringing the pet in?

First Name

Last Name

What is your phone number:

What is your pet's name?

Observed changes since previous ACUPUNCTURE visit:

[If this is your companion's initial acupuncture visit, please answer "initial visit/not applicable."]

major improvement

some improvement

no changes

some worsening

major worsening

initial visit/not applicable

If you would like to describe any changes [or have any concerns] in further detail please note them here:

[For example, "Max improved walking up stairs this week."]

Has your pet visited any veterinarians or received changes to his/her care since the last ACUPUNCTURE visit with us?

Yes

No

If you answered yes to the above question, please describe any treatment changes or where/when other vet visits were:

[For example, "my cat was seen at Sunset Animal Clinic on 5/11/2020 for a bite wound."] If your pet has NOT visited any other veterinarian or treatment change, please leave this question blank.

List any medications, including supplements and over the counter products that you use, and how often they are administered.

[Please do not write "on file," or "the same," as we need your information to be updated every visit, even if nothing has changed, and include any supplements. For example: “Pet Tab Vitamins, one every 2 days.”] If none, please write "none."

Please read and agree to the Terms of Service:

EFFECTIVE 1/1/2021: The Family Vet is a wellness clinic. Our office hours are limited to Sundays only, and all visits to our office require an appointment. We do not provide emergency/critical care nor anesthesia and radiology services. Medical problems both urgent and non-urgent may be referred to other local clinics.

I have read and understand the Terms of Service.