New Patient Form Name of Human Guardian * First Name Last Name Pronouns Email * Mobile Phone * (###) ### #### Date MM DD YYYY Address * City, State, Zip * Secondary Phone * (###) ### #### Pet's Name First Name Last Name Breed * Date of Birth * MM DD YYYY Sex * Female Spayed Male Neutored Female Intact Male Intact Color / Markings * Weight * General Practitioner Veterinarian (Name and practice name * Do you have pet insurance? If so, which company you have a policy with? * When is your scheduled appointment? MM DD YYYY How did you hear about our practice? * Referral * Reason for Today’s visit and date of onset of current history * Specify your goals for treatment * Other Current Problems * Past medical issues (dates) * Please provide specific dates and blood work results (have them emailed): * Current medications and supplements * Current and Past Diet * How is your pet's appetite? how many times a day do you feed them? * Does you pet prefer cool (hard wood floor or tile) or warm areas (sunny spots) of the house * How would you describe your pet's energy level? * How would you describe your pet's thirst? * What is your pet's exercise routine? walks? hikes? backyard? runs around the house? * Behavior: Does your pet experience anxiety? Is your pet easily stressed? What are stressors for your pet? thunderstorms? leaving the house? people coming to the door? * I understand that Dr. Alexia Tsakiris and Dr. Dallas Shim, are licensed veterinarians who focus on complementary and holistic therapies including but not limited to: acupuncture, herbal medicine, laser, food therapy and nutrition, body work, reiki, spinal manipulation, and the understanding of the human-animal bond Checkbox * I agree I understand that I am responsible for restraining my pet during acupuncture, and if I waive that right I will not be present during the treatment. I understand that a technician or I need to be alert and present so that the needles are not pulled out. * I agree I am also responsible for communicating if my pet has aggressive tendencies. I am aware that if I am not upfront about my pet's behavior, I may be asked to leave the practice for putting staff and doctors at risk. * I agree I understand that the doctors always do their best to heal their patients, and there is never a guarantee as to the outcome; as is true with all medicines and all aspects of life. I understand it may take at least 3 consecutive treatments to see how the patient responds. * I agree I understand that if I fail to give 48 hours notice for canceling or changing an appointment, I will be charged a $135 fee for a follow up appointment and $250 for an initial appointment for the disregard of the doctor’s time and that of fellow patients who would have liked that appointment time slot. I understand that payment is due at the time of services rendered, and there is a $50 returned check fee. * I agree I agree to have a general practitioner veterinarian as I understand that Naturopawthic Vet does not stock conventional medications and is unable to provide advanced diagnostics (such as x-rays). I understand the importance of a team approach for my pet's health. * I agree Pertaining to virtual appointments, I consent to the use of telemedicine for the care of my animal. Pertaining to telemedicine, I understand that Dr. Tsakiris has a limited ability and can’t conduct a physical exam via telemedicine and this may create a situation where something is missed, but will do her best and Dr Tsakiris will recommend a referral * I agree I understand the potential risks of telemedicine: include but not limited to limitations of not having a physical exam and illness and conditions may be missed, the info that is transmitted may not be sufficient, lack of medical records may result in an inaccurate diagnosis, may be delays in medical evaluation or treatment due to deficiencies or failures of equipment, information shared may not be sufficient for diagnosis or treatment, illnesses or conditions may not be observe diagnosed or treated, does not allow a physical exam, lack of medical records may result in an inaccurate diagnosis, adverse drug interactions, or allergic reactions, or other medical judgement errors. * I agree I understand that my pet needs to be examined bi-annually to maintain a doctor-patient relationship. * I agree I understand that I am responsible for submitting insurance forms and claims to my pet insurance company * I agree By signing below I authorize Dr. Alexia Tsakiris, Dr. Dallas Shim and their assistants to administer such treatment and or perform such diagnostic procedure as agreed upon, send periodic emails, and to pay my balance in full at the time of services rendered. It is understood that no guarantee or assurance has been made as to the results that may be obtained. I assume full financial responsibility for all charges incurred by my pet(s). * I agree Thank you!