Veterinary Acupuncture Intake Form Veterinary Acupuncture Intake Form Name * Name First First Last Last Phone * Email * Pet's Name * Species * Breed * DOB/Age * Sex * Spayed Female Unaltered Female Neutered Male Unaltered Male Unknown What is the main reason you are seeking acupuncture for your pet? * Health problem(s) General wellness If health problem(s) was selected above, please describe. What is your primary goal with acupuncture? What do you hope to achieve? * What diagnostics have previously been done and what were the results? (Ex: blood work, x-rays, etc) * What treatment(s) have you utilized? * Did your pet show any improvement? * Yes No If you answered the above answer as YES, please describe. Since your pet's last veterinary visit, they are * The same Better Worse If you are human, leave this field blank. Next
