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New Patient Paperwork
NEW PATIENT FORM
APPOINTMENT POLICIES
Home
About
Services
Contact
New Patient Paperwork
NEW PATIENT FORM
APPOINTMENT POLICIES
NEW PATIENT FORM
WELCOME TO ENABLED INTEGRATIVE VETERINARY SERVICES
PLEASE FILL OUT OUR NEW PATIENT and CONSENT TO TREAT FORMS
Date
(Required)
MM slash DD slash YYYY
Client Name
(Required)
First
Last
Address
(Required)
Street Address
City
State
ZIP Code
Email
(Required)
Phone
(Required)
Best Way to Contact
Phone
Text
Email
Patient Name
(Required)
Name
Pet Date of Birth
(Required)
MM slash DD slash YYYY
Species
(Required)
Dog
Cat
Equine
Other
Sex
(Required)
Male
Male - Neutered
Female
Female - Spayed
Horse - Gelding
Horse - Stallion
Breed
(Required)
Color
Weight
Microchip Number
Vaccine History
UP TO DATE ON VACCINES- Please document type of vaccine and date given below.
VACCINE TITERS- Please document type of vaccine titer, date given and results of titer below.
VACCINE REACTION- If yes, please document with details below.
Vaccine Information
Preventatives
Diet
Raw
Gently Cooked
Homemade
Dry/Kibble
Canned
Other
Food Brand
How Many Times a Day Does Your Pet Eat?
Quantity
Have There Been Any Recent Changes to Your Pet's Diet?
Yes
No
Please describe changes and impact on your pet...
Medication/Supplements
Yes
No
Please list all TYPES, BRANDS, DOSAGES, and FREQUENCY...
Exercise
Prior Illness, Injury, or Emotional Issues
Yes
No
Please describe any previous illness, injury, or emotional issue...
Diagnostic - Please Upload Copies Prior to Appt.
Diagnostic Documents
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, webp, heic, Max. file size: 128 MB.
Reason for Visit?
What Has Been Done to Address This Concern?
Additional Concerns or Comments
Consent for Treatment
(Required)
I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent.
• I have also been informed that there are certain risks and complications associated with any procedure of this type. Such procedures may include chiropractic care, acupuncture, laser therapy, ozone therapy, or other___________________________________________.
•Procedures have been explained to me as well. I further understand that while the procedures, unforeseen conditions may arise that may necessitate the performance of additional measures. Such procedures or treatments do not guarantee to be curative. I expressly authorize such treatment and release Enabled Integrative Veterinary Service P.C, its Doctors, and staff from all liability and claims except those arising from gross negligence.
• I authorize the use of appropriate pain relief medication and supplementation as needed before or after the procedure. I have been informed that there are risks associated with the use of any medication. I understand the hospital support personnel will be used as deemed necessary by the veterinarian.
Client Name
(Required)
Client Name
Pet Name
(Required)
Pet Name
Client Signature
(Required)
Signature
Date
(Required)
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.
