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Holistic Wellness Counseling, Veterinary Acupuncture and Therapeutic Laser Treatment

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For NEW clients: unfortunately, at this time I am unable to accept new clients.
For EXISTING clients: please complete this form if you adopt a new pet.

I will update this page when I have availability.

Client / Pet Information Form

Please complete this form to request an appointment. Dr. Keller will contact you within two business days.

Date

YYYY

Client Name

First Name

Last Name

Email Address

Spouse Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Place of Employment

How Did You Learn About My Practice?

Desired Meeting Location

Please select a location. Addresses and price details appear on the Cost of Services page.

Pet Information

Pet Name

Pet Species

Pet Sex

Pet Date of Birth

YYYY

Pet Adoption Date

YYYY

Pet Weight

Pet Breed

Pet Color and/or Markings

Describe Past Illnesses, Surgeries, Accidents, Fractures

List and Describe Any Vaccination Reactions

Canine: Provide Date of Most Recent Bordatella, DA2PP, Lepto, Rabies

Feline: Provide Date of Most Recent PCVR, FeLV, FiV, Rabies

Has Pet Ever Had a Vaccine Titer Instead of a Vaccine?

Yes

Is Pet on Heartworm Preventive, and if so, what product?

Is Pet on Flea and Tick Preventive, and if so, what product?

List Current Medications and/or Supplements

Describe Reason for Housecall and Goal of Treatment

Describe Pet's Normal Daily Activity and Exercise

Describe Pet's Diet and Provide Name(s) of Product(s) Used

Name of Current Veterinarian and Hospital

Do you have any relevant lab tests, x-rays or records that I may view before or during your appointment?

Yes

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