Holistic Consult Form

Thank you for your interest in scheduling a consultation with our doctors. Please be sure that you fill out this form as soon as possible after scheduling your appointment. If we do not receive your completed form and all relevant records within 3 business days of your appointment, you may be asked to reschedule.

Owner Information

Owner Name *

Address

Apt, suite, etc.

Country

City

State

Zip code

Primary Phone *

Secondary Phone

Email *

How did you hear about us? *

Have you read Dr. Morgan’s book?

Have you watched Dr. Morgan’s webinars

Pet Information

Pet's Name *

Type of Pet *

Dog

Cat

Other

Breed

Date of Birth mm/dd/yy

Birthdate may be entered as mm/dd/yy or you may scroll through the calendar to pick the correct date.

Color

Weight

Pet Weight Description *

Sex *

Male

Female

Is Pet Spayed or Neutered?

Yes

Adopted/Purchased from

At Age

Number of Pets in the House

Where does this pet fit in the pack?

How does this pet behave around strangers/other animals?

Current Diet and Treats

List any supplements pet is currently taking

Include name of supplement, strength/dose, and how often given.

List any medications pet is currently taking

Include medication name, strength/dose, and how often given

List Medical History

Include a brief description of each Problem/Disease, Age at Onset, Treatments Tried and if they were successful.

Surgical History

Include surgery performed, and date (year)

Has your pet seen any specialists? *

If "Yes", what for?

Where does your pet sleep?

Does (S)he like to snuggle under blankets?

Does your pet pant a lot?

Does your pet drink a lot or a little?

Does your pet urinate a lot?

Any difficulty urinating?

Any vision or hearing problems?

How much time does your pet spend outdoors?

Does your pet prefer hot weather or cold?

Describe your pet's tongue (color, size, wet/dry)

Describe your pet's foot pads (color, texture)

Describe your pet's nose (color, texture, wet/dry)

Describe your pet's skin

Describe your pet's coat

Describe your pet's ears (warm, cold, neutral; odor, discharge)

Describe your pet's poop

Are you willing to cook for your pet?

Would you prefer a diet that is already prepared?

Are you willing to feed a raw diet?

Do you own a grinder?

Do you own a crockpot?

What specific issues would you like addressed?

What are your major concerns?

Previous Veterinarian Office(s) Name and Phone Number

Please bring a fecal sample to your appointment!

This sample should be collected no more than 24 hours before the appointment and can be brought in a plastic bag or a disposable container.

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Clayton Veterinary

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