Integrative New Client Form Integrative New Client Form Hello and welcome to Lane Veterinary! I am so excited you are interested in an integrative approach. I am here to support you and your beloved companion and cannot wait to learn more about your pet and meet you. - Dr. Lauren Beaird Please be sure to send a complete medical history from your previous veterinarian(s) no less than 1 week prior to your visit. Records should include both general practice and specialty records, if applicable. They can be sent to pets@lanevet.com. Collecting a patient history and understanding your goals and expectations for your pet's health during your first visit will take up a considerable amount of the 60 minute appointment. Take your time when filling out this form and submit at least one week prior to your visit (when applicable). Please consider spending 30 minutes (or more if needed) of focused time on this form. A thorough history will help us create an individualized plan for your pet before we meet. During the visit we will discuss this plan of action and adjust it to meet your expectation and individual goals. Have you ever brought a pet to Lane Veterinary before? * Yes No Name * Name First First Last Last Phone * Email * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Is There a Spouse/Partner/Family Member Who Should Be Listed On Your Account? * Yes No Section Spouse/Partner/Family Member Name Spouse/Partner/Family Member Name First First Last Last Please tell us how the above person is related to you so we can refer to your relationship appropriately. Spouse/Partner/Family Phone Spouse/Partner/Family Email Is there anyone else (besides above listed contacts) who should be listed on your account, who has ongoing permission to make medical decisions for your pet(s)? * Yes No Section Additional Account Name Additional Account Name First First Last Last Please tell us how the above person is related to you so we can refer to your relationship appropriately. Contact Number Emergency Contact Name Emergency Contact Name First First Last Last Please tell us how the above person is related to you so we can refer to your relationship appropriately. Contact Number How did you hear about us? (Ex: Social media, walking by, etc.) * Please tell us who we may thank for your referral! Pet's Name * Upload A Picture Of Your Pet Drop a file here or click to upload Choose File Maximum file size: 52.43MB Species * Dog Cat Other (please note, we are a canine and feline only clinic) Date of Birth / Age Of Your Pet * Breed (If your pet is not a known breed, do they have long, medium or shorthair?) * Color * Is your pet microchipped? * Yes No Do you have more than one pet in your household? * Yes No Please list name, sex, breed, color and age for additional pets. Primary Reason for a visit to Lane Veterinary? * Do You Already Have a Scheduled Appointment? * Yes No Appointment Date * Appointment Time 121234567891011 : 0030 AMPM General History Please provide a detailed list of your goals and expectations. * Your primary concern for your pet. * Additional health concerns. If you suspect your pet has concerns with any medication, prevention, medical treatments/injections, vaccinations, foods, treats, etc. Please list them here. I want to be mindful of these when I am making personalized recommendations for your pet. * What food are you feeding? Please be specific with brand, and full name of diet (including protein/flavor/meat), how much and how often you are feeding. * What treats, chews, etc. are you feeding at home? Please be specific. * Please provide a comprehensive list of any medications, preventions, supplements, and topicals you are using with your pet. Include the amount you give and how frequently. Be specific with brands as well if applicable. * Are you open to dietary recommendations/changes such as balanced lightly cooked foods or commercially prepared raw foods? Please explain any concerns or questions you may have regarding a diet change. * Please list any additional questions/concerns you would hope to address. If you are human, leave this field blank. Next
