Name *

First Name

Last Name

How did you hear about us? *

Online / Website/ Google

Instagram /Facebook

Primary Veterinarian

Referral from a friend

Other

How much experience do you have with Chinese or Alternative/Complementary/Holistic medicine?

I am experienced and very familiar with the concepts

I've heard about it and I am open to options

I am not familiar with it and would love to learn more about how it benefits my pet

How much information do you want to be given about your pet’s health? *

I want a full explanation—anything and everything.

I want a brief explanation—just the important stuff

I just want to know if there’s anything I need to do—keep it simple.

Pet's sex *

Male

Female

Spayed/ neutered? *

Yes

No

Has your pet ever had a reaction to vaccines or medications? *

Yes

No

Has your pet shown any aggression towards people or other animas? *

Yes

No

Payment is due upon service. A non-refundable scheduling fee is necessary to secure all appointments, and this fee will be applied as credit towards your consultation. To ensure convenience, we accept major credit cards and cash *

Debit/Credit

Cash

You will be asked to sign a health plan confirming authorization of treatment. The details of treatment, the risks of treatment, and/or the risk of not treating will be explained to you. *

I have read and understand