First Name *

Last Name *

Email *

Phone *

Pet Name *

Pet Breed *

Pet's Age *

Pet Weight *

Appointment date/time (or staff member you spoke with): *

1.) Top 1-3 concerns (short paragraph): *

Top 3

2.) When did this start? *

3.) What have you tried so far? What helped / did not help? *

4.) What would success look like in 4-8 weeks? *

Diagnosed conditions (list): *

Current medications (name / dose / frequency): *

Supplements / herbs / CBD (name / dose / frequency): *

Past surgeries / hospitalizations: *

Vaccine history (recent? any reactions?): *

Parasite prevention (flea/tick/heartworm): *

Allergies or adverse reactions (food/meds/vaccines): *

Prior alternative treatments tried (Check all that apply and describe below: *

Acupuncture

Rehab/physio

CBD

Chiropractic

Herbal

Raw/food therapy

Chiropractic

Homeopathy

Other

Describe what was done: *

What helped? What did not help? *

Current diet (brand/protein/flavor; amount per day): *

Treats/chews/table scraps (what + how often): *

Water intake: *

Low

High

Normal

Other

Describe water intake: 

Appetite: *

Normal

Picky

Increased

Decreased

Other

Describe Appetite:

Vomiting frequency (if any): *

Stool quality + frequency (normal/soft/diarrhea/constipation): *

Gas/bloating? *

Any known food sensitivities? *

Energy level (low/normal/high; changes?): *

Exercise (type + duration): *

Sleep (check all that apply): *

Restful

Paces at night

Vocalizes

Wakes at night

Accidents at night

Sleep notes: *

Stress triggers (separation, noises, vet visits, other pets, etc.): *

Anxiety/fear/aggression? Describe: *

For seniors: cognitive changes (night waking, pacing, confusion, accidents, vocalizing): *

Itching/licking/hot spots? *

Ear infections/head shaking? *

Coughing/sneezing/wheezing? *

Signs of pain (limping, stiffness, reluctance to jump, yelping, etc.): *

Mobility changes (stairs, slipping, weakness): *

Previous injuries/diagnoses (arthritis, IVDD, hip dysplasia, etc.): *

Heat/cold preferences (TCVM clue), check all that apply: *

Seeks warmth

Seeks sun

Avoids cold

Dislikes heat

Pants easily

Warm ears/paws

Seeks cool floors

Cold ears/paws

Home type (apartment/house; yard; stairs): *

Other animals in home (species/ages): *

Do they get along with other animals (in home and outside the home)? *

Any recent life changes (move, new baby/pet, travel, stress): *

Chemical exposures (lawn pesticides, cleaning products, essential oils, diffusers): *

Smoke exposure (tobacco/cannabis/air quality issues): *

For intact females: heat cycle notes; discharge; pregnancy history: *

For all pets: known or suspected hormonal diagnoses (e.g., Cushing's, Addison's, thyroid, diabetes): *

For intact pets: is your pet a breeding animal? *

Yes

No

If you have records you would like to share, please email them to [email protected] (PDF preferred).Records you plan to send (check all that apply):

Medical records

Medication list

Check here if you are uploading/sending records for this visit.

Discharge summaries

Imaging reports

Recent labwork

Photos/videos

Consent 1 *

I understand acupuncture commonly requires a series of visits for best results.

Consent 2 *

I understand acupuncture is a complementary modality. While it can sometimes be used alone, it is often most effective when combined with appropriate Western diagnostics and medical management. Western diagnostics (such as bloodwork, imaging, and urinalysis) are often the most useful tools for identifying underlying disease processes and guiding safe, effective integrative care.

Consent 3 *

I understand the risks of acupuncture (uncommon): temporary soreness, bruising or minor bleeding at needle sites, transient fatigue or symptom flares, needle sensitivity or stress, and rarely infection or needle breakage. Certain point locations can carry very rare risks (e.g., pneumothorax) when performed improperly; Eden Veterinary uses appropriate technique and precautions to minimize these risks.

Consent 4 *

I understand there is an increased risk for medically fragile or geriatric pets in TCVM: acupuncture may 'move Qi' and, in severe Qi deficiency or extreme frailty, this can rarely contribute to decompensation. This risk is uncommon and most relevant for very fragile geriatric patients; we will tailor point selection and intensity to my pet's condition.

Consent 5 *

Communication Consent: Eden Veterinary may contact me regarding scheduling, estimates, my pet's care, and follow-up (phone/text/email). To update communication preferences, I will email [email protected].

Consent 6 *

Telemedicine (if applicable): I consent to remote consultation and understand that telemedicine has limitations compared with an in-person exam, and an in-person assessment may still be recommended.

Consent 7 *

I authorize Eden Veterinary to communicate with my primary veterinarian and share/request relevant records as needed.

Primary veterinarian / clinic name (optional):

Date of Signature:

Signature: 

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