Holistic / Rehabilitation Client Form"*" indicates required fields Step 1 of 333%Client Name* First Last Spouse / Partner Name First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneBusiness PhoneCell Phone*Spouse / Partner PhoneEmail* How would you prefer to be contacted? Phone Text EmailHow did you find out about Cashmere Veterinary Clinic? Referral from my veterinarian Referral from a friend / family member Found on the internet (Google search, Facebook, etc) OtherPlease enter your veterinarian's nameWho can we thank?Pet's NameGender Male FemaleSpayed / Neutered Yes NoIs your pet microchipped? Yes NoDo you have pet insurance? Yes NoSpecies* Canine FelineBreed*Weight (lbs)*AgeYearsMonthsWeeksWhat is your main concern (What are you seeking treatment for)?Primary ComplaintDuration of ProblemYearsMonthsWeeksPast treatments for this conditionWere past treatments effective? Yes No Some (please explain below)ExplainDiet & amount fed (please list specific brand, dry/canned, as well as any treats regularly given)How is your pet's appetite? My pet loves to eat My pet is picky My pet is not food motivatedHow is your pet's water intake? Increased Decreased Frequent small sips Large amounts at one timeDoes your pet have any food allergies? Yes NoWhat Allergies?Your pet's urination is Normal Increased Decreased Incontinent Straining / VocalizingThe urine appears Normal Dark Clear Bloody Large Volumes Small volumeYour pet's stools are? Normal Increased Decreased Diarrhea Blood/mucus in stools Incontinent Excess GasYour pet's skin/feet/nails? Dry skin with large flakes Dry skin with small flakes Brittle nails Dry foot pads Itchy skinWhen is your pet most itchy? Only sometimes During the day At night All the timePlease describe any coat changes or lesions you have noticedYour pet's respiration/breathing? Normal Coughs Has had a change in breathingDescribe any changes in breathingHas your pet's voice or noises that he/she makes changes at all? If so, please describeDoes the condition inhibit activities? If so, which activities?Does your pet have problems with any of the following? Check all that apply Slippery Surfaces Uneven Surfaces Mild Inclines Short Walks Long Walks Stairs Posturing for urination Posturing for defecation Accidents Difficulty sitting Difficulty standing Difficulty rising from sitting Difficulty walking Limps during walking (Indicate which limb) Difficulty running Painful or lame following exercise OtherWhen are signs the worst? First thing in the morning Late in the day During activity After activity After rest Same all the timeActivity level prior to injury? (indicate all that apply) Leash walk Leashed jog/run Off leash park/free play Activity play (ball, Frisbee, etc.) Competitive athlete (i.e. agility, flyball, etc.)Does your pet seem to be in pain? If yes, please grade (1 = mild, 10 = severe) and whenDo you see your pet stretch during the day? Yes NoHas their stretch changed? Please describeEnergy and Well-BeingHow is your pet's energy level? Normal Reduced IncreasedWhen is your pet's energy level the highest? Morning Afternoon Night ConsistentWhen is your pet's attitude the best? Morning Afternoon Evening Night ConsistentHow would you describe your pet's personality? Outgoing Shy Aggressive Content Restless Crabby DepressedDoes your pet prefer? To be cool To be warm No preferenceHow is your pet's sleep schedule? Normal Decreased Increased Restless at night Has frequent dreaming/vocalization/running in sleepPlease describe where your pet sleeps:Has your pet had behavioral changes recently? If so, please describeHave you noticed any irritability in your pet? If so, when & why?Has your pet ever demonstrated aggressive behavior? If so, when & why?Current medications (please list all prescribed and over the counter medications including dosage and frequency given)Current dietary supplements & herbal therapies (please list all)Other medical history (ex: seizures, heart conditions, respiratory conditions, surgeries, etc.)Does your pet have any past history of cancer? If yes, what type and when diagnosed/how treated?What specific goals are you seeking for your pet through treatment?Are you able/willing to do prescribed exercises at home as part of your pet’s rehabilitation therapy?Select all vaccines your pet is up to date on(Canine) DAPP Lepto Bordetella RabiesSelect all vaccines your pet is up to date on(Feline) FVRCP FelV RabiesWhat veterinary clinic can we verify these vaccinations with?Are there any of veterinary clinics previous medical records can be found at? (Including surgeries, x-rays, bloodwork, etc.)Washington State requires all pets to be up to date on rabies vaccination to be seen by a veterinary clinic. If your pet is not up to date on rabies, are you willing to have your pet vaccinated prior to treatment? Yes NoIf no, why?Home environment (Check all that apply) Other animals Short flight of stairs Primarily carpet in home Long flight of stairs Primarily tile/hardwood/linoleum in home More than 50% of time outdoors in yard each day Sleeps on owners bed Access to dog door during day Jumps onto bed or sofa Young children at home Free access to house at night Access to dog door during night Small yard Large yardAll fees are due at the time services are rendered. Please indicate choice of payment. Cash/Check Visa Mastercard Discover Care Credit ScratchPayMake my pet a social media star! I authorize and grant Cashmere Veterinary Clinic permission to take a picture of my pet and use it on social media (Facebook, Instagram, Twitter). Yes! No, thank youRecord Release I agreeSometimes boarding facilities, groomers, referral hospitals, etc. may request records to be faxed. We are asking at this time for your consent to do so if requested.I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, OR TREAT THE ABOVE-DESCRIBED PET(S). I ASSUME RESPONSIBILITY FOR ALL CHARGES INCURRED IN THE CARE OF THIS ANIMAL . I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF RELEASE AND THAT A DEPOSIT MAY BE REQUIRED FOR TREATMENT.Sign (Enter Full Name)Date MM slash DD slash YYYY
