Great Paws Veterinary Hospital

Great Falls
Great Falls, Va 22066

(703)389-9335

www.greatpawsvet.com

Acupuncture and Chinese Herbal Medicine Intake Form

Great Paws Veterinary Hospital offers acupuncture and Chinese herbal medicine to our valued clients.

Animal Species: (required)

Canine
Feline

Animal Name: (required)

Breed: (required)

Color: (required)

Animal Age:

Animal Weight:

Caregiver Information

Caregiver Name: *(required)*

First Name (required)	Last Name (required)

Phone: *(required)*
Phone Type	Phone Number (required)

E-Mail Address (required) :

Today's Date: (required) :

Referred By:

Has your pet ever shown aggression toward another pet or person? (please explain briefly if needed):

What is the pet’s general demeanor at home? (select one): (required)

Likes to be the center of attention
Friendly but Laid Back
Aloof
Fearful
Dominant

Do you authorize your pet’s photo (if taken) to be placed on social media to promote TCVM/Great Paws Veterinary Hospital (required)

Yes
No

Medical History (diagnosed conditions): allergic skin disease, behavioral abnormalities, cardiac disease, seizures, spinal disease, cancer

Main complaint(s) for today’s TCVM visit: (required)

Diet (brand, protein type, dry or canned): (required)

Housemates:

Please select the appropriate response for the following:

Voice (Bark/Meow): (required)