New Client Information

First / Last Name:
Employer:	Occupation:
Spouse's First / Last Name:
Spouse's Employer:	Occupation:
Mailing Address:   City:   State:  --Ala.AKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY  Zip:

Cell Phone:		Primary
Home Phone:		Secondary
Work Phone:		Secondary
Spouse Phone:		Secondary

**We respect your privacy and will never share your information without your consent. We use email as a form of primary communication to relay important information / changes about our hospital while also sharing upcoming promotions and important educational health information. In addition, you may receive your pets healthcare reminders.

Email:  

Is there anyone else you would like to add to the account that could have access to your pet's healthcare information (family member, pet sitter, etc)? 
 

First and Last Name:

Contact Number:

Relationship to you or your pet:

Additional Information
Do you plan to make this practice your primary veterinarian?         Yes              No
How did you hear about us?  

Yelp	Google/Website	Facebook/Instagram	Magazine Ad	YouTube
Community Event:
Word of Mouth or Existing Client/Employee Name:			Other:

It is important to us as an Integrative Animal Hospital to understand how you would like us to discuss healthcare options for your pet.  How much of a Holistic (natural) approach do you prefer in your pet’s health?  
(1 being the lowest; 4 being the highest):      1    2     3     4    

Treatment Consent
 

I, the owner of the patient(s), hereby authorize the veterinarians and staff of Mountain View Animal Hospital & Holistic Pet Care to examine, treat, and prescribe the necessary medication for the above-listed pet. This includes but is not limited to, procedures therapeutically and/or diagnostically. I understand that no guarantee of successful treatment is made. I further understand that this facility has a doctor on staff between 7:30 am to 5:30 pm only, therefore, there is no continuous presence of doctors after regular business hours.  I certify that all the information above is correct, that I am the rightful owner or authorized agent of this pet(s), and that I am at least 18 years of age. Mountain View Animal Hospital & Holistic Pet Care does not operate as an emergency hospital and although we will always try to be available, I understand I may be referred to an emergency hospital even during open hours if the veterinary staff feel it is in the best interest for my pet(s). 
I understand by Nevada pharmaceutical law, all prescriptions including herbals that leave the hospital are non-refundable.       
Payment Policy
Please note: All fees incurred at Mountain View Animal Hospital & Holistic Pet Care are required to be paid upon time of service. We do not accept payment plans or delayed billing.  Any unpaid balance left unpaid are subject to accrued 1.5% interest after 30 days, and balances left unpaid for more than 90 days will be sent to collections in addition to a 40% collection fee.   There is a $35 charge for each returned check, and we do not accept any postdated checks. We accept Visa, Mastercard, American Express, and CareCredit & for established clients (been here at least 2 times) we also accept checks. Any credits placed on the account must be utilized within 2 years of the date they were added.
I acknowledge that I have read and understand the Payment Policy.

Cancellation Policy
We request that any cancellations be made at least 24 hours prior to the start of your pet's medical appointment or grooming appointment reservation. If you cancel without ample notice or do not show up to your appointment or boarding/daycare reservation you may be required to pay a cancellation fee. This fee is non-refundable and cannot be applied toward any other services.
I acknowledge that I have read and understand the Cancellation Policy.


 I have read, understand and accept all the information above.

 

Pet First Name:	Last Name:
My pet is a:      Dog         Cat       Other:
DOB / Approximate Age:	Breed:
	Color / Distinctive Markings:
My pet is:       Female Spayed      Male Neutered      Female Intact     Male Intact

Known Allergies (to medications, food, environment): As a Fear Free Clinic we emphasize lots of cookies at our visits. If your pet has allergies - please let us know and feel free to bring your special treats from home!


Current Diet (check all that apply):
 Kibble      Canned/Wet      Home Cooked      Freeze Dried / Dehydrated     RAW
How often do you feed?

Current Medications / Supplements: Please include any preventatives (such as Heartgard) & over-the-counter supplements. If possible, the milligram dosage, dosage frequency, and when the last dosage was given. 

1.
2.
3.
4.
5.

Any additional information you would like us to know about your beloved pet: 

 

At Mountain View Animal Hospital and Holistic Pet Care, we LOVE to share our patient's cute faces! We try to photograph their success stories, "spa days", playing with our staff, and really any moment we can capture that expresses that love! In addition, we add your pet's picture to their medical profile for safety and identification purposes.  With this, we require authorization.

I hereby grant Mountain View Animal Hospital and Holistic Pet Care permission to use any photographs taken of my pet in all its publications, including website and social media entries.  I understand this is voluntary and I am aware I will receive no compensation.  I understand and agree that these materials will become property of the hospital.  I hereby release the hospital and its employees from any claims, demands, and causes to action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or the behalf of my estate, have or may have by reason of this authorization.  

In signing this consent, I give authorization of the following (check any that apply!):

 The Use of My Pets Photo for Medical Record Identification Purposes ONLY

 The Use of My Pets Photo for Medical Record Identification Purposes AND Social Media

 The Use of My Photo if I am in the picture with my pet and/or offering to share my experience on social media

 I decline all media consent, understanding that declining pictures of my pet in the medical record system may inhibit staff from correctly identifying my pet.
 

Our staff is trained to physically manage, hold, or otherwise restrain your pet in the safest and most comfortable way. Should you decide that you wish to assist during exams or procedures, our staff and hospital shall not be held liable for any injury that may arise, whether it be done to or by your pet. 

I have read and understand the release of liability for holding my pet and the media consent form and have been given the opportunity to ask any questions. 



Printed First and Last Name 

 

As an Integrative Animal Hospital, we believe the best medicine has a combination of scientifically proven western treatments combined with Natural (Holistic) treatments. This detailed history helps our Integrative Doctors establish a Holistic Medical Diagnosis and Five Element, aiding in our overall treatment approach and herbal recommendations. We encourage you to fill this form out anytime you feel there are major changes in your pet's history.  You may ask for this form at any of your recheck examinations and annual exams!   

Please List your Primary Concerns today: 
1. 
2. 
3.   

Please Check off All that Apply:
 

1. Appetite

Normal Expectation

Ravenous

Poor

Eater and/or Not Food Motivated

 

2. Thirst

Normal Expectation

Loves Water

Not a Big Drinker

Unsure

 

3.  Feces	Normal	Consistently Dry	Consistently Soft	Mucus
	Malodorous	Bright Red Blood	Dark Black	Yellow/Orange
	Incontinent (unable to hold in fecal material) Date it started:

 

4. Urine	Normal	Urinate frequently	Does not urinate frequently
	Leaking/Dribbling	Large amounts	Small amounts

 

5. Urine Smell

Strong

Little Smell

None

Unsure

 

6. Urine Color

Clear

Slightly Cloudy

Cloudy

Turbid

Unsure

 

7. Voice

Very Vocal

Soft Voice

Loud Voice

Doesn't vocalize/Hardly Ever

 

8. Behavior	Normal Expectation
	Friendly
	Anxious around
	Fearful of
	Aggressive around
	Hyperactive  / Overly Exuberant
	Sluggish
	Calm / Reserved

 

9. Sleep	Great sleeper	Restless/Agitated	Insomnia/Can't sleep
	Snores	Dreams	Unsure
	Other:

 

10. Hair Coat	Soft/Shiny	Dry/Dull	Dander
	Excessive Shedding	Balding	Texture or Color Changing
	Other:

 

11. Skin	Normal	Greasy / Oily	Large Dandruff Flakes  Small Dandruff Flakes	Rash
	Brittle	Thinning	Itchy	Bad Odor
	Other:

 

12. Temperature Preference	Loves Sun/Heat	Loves Cool / Shade / Laying on Cool Floors	Either / Neutral
	Other:

 

13. Surface Preference	Hard Surfaces/Floors	Soft Surfaces / Bedding	Neutral
	Other:

 

14. Stiffness, if present is WORSE after:
	Rest	Exercise	Both	Unsure
	Cold Weather	Warm Weather	Unsure	Other:

Please check any Chronic Problems your pet has/is suffering from:
 

1. Eyes	Dry Eyes	Excessive Tearing	Red Eyes	Corneal Ulcers	Glaucoma
	Other:

 

2. Ears	Chronic Ear Infections	Ear Hematomas	Itchy Ears
	Other:

                      

3. Tongue	Dry	Excessively Wet / Abnormal Drooling	Red	Purple	White
	Other:

 

4. Mouth	Dry	Excessively Wet / Abnormal Drooling	Red	Purple	White
	Other:

 

5. Nose	Dry / Cracked Nose or Skin Above Nose	Sneezing / Reverse Sneezing	Red	Purple	White
	Other:

  

6. Digestive	Vomiting Intermittently	Vomiting Daily	Vomits Bile
	Vomits Grass	Vomits Whole Food	Vomits Blood

                     
In general, do you feel your pet smells? If so, how would you describe it?  
  Rancid       Scorched      Fragrant      Rotten       Putrid     Other:                              

We LOVE our Clients and Patients!

Dear Valued Client, due to the recent surge in pet adoptions, staffing shortages, and population growth, the veterinary industry is managing scheduling challenges nationwide. For clear communication and a mutually rewarding relationship, we ask that you please read and check the box indicating that you've been notified, agree, and understand. Thank you!

I have read and acknowledged the statements above.

Five Element Quiz

Traditional Chinese Veterinary Medicine (TCVM) uses a system of classification called the 5 elements. The 5 elements apply to personality, disease predisposition patterns, and dietary considerations. This article will help you understand the primary elemental personality type of your dog, and feed accordingly.
 

Fire
Lively Communicative Very Friendly Affectionate Loves to be Pet Center of the Party	Insomnia Separation Anxiety Restless Excess Heat Rapid Heart Rate Heart Problems

Earth
Relaxed & Laid Back Sociable Round & Large Loyal Serene & Balanced Motherly	Diarrhea Constipation Loss of Appetite Vomits Gum Disease Weak Muscles Over Eats Worries

 

Wood
Decisive Assertive Confident Strong Willed Impulsive Athletic-Stamina Alpha	Ligament Problems Liver Problems Red Eyes Anger's Easily Ear Problems Nail/Food Pad Issues Anal Gland Issues

Water
Careful Curious Self-Contained Likes to Hide Meditative Slow & Consistent	Rear Weakness Fearful Bone/Back Issues Urinary Problems Disturbed Growth Reproductive Issues

 

Metal
Loves Order Obeys the Rules Aloof Symmetrical Body Disciplined Attitude Good Haircoat	Asthma Dry Skin Sinus Issues Breathing Disorder Nose Problems Cough

 




 



  Fire personality animals are very jovial and love life. They are the type of dog that is going to be bursting with happiness to see you and possibly try to give you as many kisses as you will allow in greeting. Fire animals also tend to be very vocal often expressing themselves with a wide variety of sounds, besides the typical bark. These animals love attention and want to be the star of the show. These animals will strive to do what their people ask of them as they love the reward. Fire dogs are often considered hyper.
  Earth personalities are very friendly and loving dogs, but also are okay with time to themselves. They are nurturers and like to care for others. They generally have a happy, laid-back personality and are up for whatever their people feel like doing. Earth personalities tend to be slower moving, and often need more sleep than other personalities. Earth tends to think a lot about how to take care of their owners or others in the household and this makes them prone to the emotion of worry which can lead to gastrointestinal upset. However, Earth personalities tend to have longer life spans!
  Wood personality animals are generally very confident animals. This is a dog that is not usually afraid of anything and may charge right up to you in greeting or sit next to their owner barking a warning. However, they are often very friendly with people they know, you just have to be approved first. These dogs are very loyal and want to please their owners. They are very driven to win. 
  Water personality animals tend to be very quiet and reserved. They are the most introverted of personalities and tend to be more independent and solitary, even when in familiar surroundings. Like the Metal personality, Water likes to analyze the situation before acting. Water types are prone to the emotion of fear. These dogs are hesitant and tend to look to their owners for guidance in new situations. Most water animals prefer to hide or run but will bite or scratch if unable to avoid unwanted interactions / perceived danger.
  Metal personalities tend to be leaders due to their confidence and consistency. They are quiet and independent, seeming aloof, but they like to analyze the situation before getting involved. They are not unfriendly, just reserved. Metal personalities enjoy rules and order and like to have a job and a set procedure for their daily routines. This dog will expect you to also follow a schedule and will let you know if you are late feeding them or when it is time to go for their walk. They are driven to succeed and will not pay attention to anyone or anything at a dog park or when someone comes over to the home if they have a job to do.


I understand all of the information above and I agree that the information that I have filled out is correct.


Printed First and Last Name 


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