Today's Date

OWNER INFO

Owner's Name

First Name

Last Name

Occupation

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile

(###)

###

####

Home

(###)

###

####

Work

(###)

###

####

Secondary Caregiver of Pet

First Name

Last Name

Occupation

Phone

(###)

###

####

PET INFO

Pet's Name

Species

Canine

Feline

Breed

Sex

Female

Male

Spayed/Neutered

Yes

Date of Birth

Approximate date or age if not known

Video Thoughts

What are your thoughts on the new patient videos that you just watched?

Please explain how you are familiar with these areas of holistic health. If none, put N/A.

Have you experienced muscle testing? Have you ever been cared for nutritionally? Etc.

When/where did you obtain your pet?

Current Problem

PET DIET

Current Diet

Please tell us everything about your pet's current diet. Include details about your pet's appetite, typical daily feeding routine, type of food (dry/wet/raw), brand(s), flavor/protein, amount given per meal, any treats, "human food," fruits/veggies, etc. Please be as specific as possible.

How long has this current diet been fed?

5 years, 5 weeks, etc.

Water

What type of water are you offering your pet?

List any supplements currently given:

Please include the name of the brand.

PET HEALTH HISTORY

Veterinary clinics my pet has been to:

Please list all clinics and phone numbers your pet has been to.

Vaccination Comments

We have found that overvaccination causes chronic health issues. At our office, we do a minimal vaccination protocol. Initial vaccinations create immunity that lasts years, rendering annual vaccinations useless. To prove this, we do annual titer testing. Titer testing is a quick in-office blood test that measures antibody levels from previous vaccinations. This test will tell us if your pet has sufficient immunity and whether or not another vaccination is needed. There are some vaccinations that we do not even recommend such as Bordetella. In lieu of these vaccinations, we put our focus on nutrition and strengthening the immune system.

Heartworm Preventative

We believe overmedicating can cause more harm than good. Our protocol is to do an annual in-office heartworm test, then give heartworm tablets every other month from July to November (that is 3 doses per year for dogs living in Michigan.) Check out our website for more information!

Flea and Tick Preventative

Depending on your pet's behavior and where you live, flea and tick prevention may not be needed at all. We recommend using high quality essential oils, daily brushing, and/or herbal supplements that provide natural flea and tick prevention before utilizing medication. Check out our website for more information!

PET ILLNESS HISTORY

Please list all illnesses your pet has experienced:*

Please list these in order from oldest issues to most recent. Illness can include skin allergies, ear infections, eye issues, diarrhea/vomiting, skeletal problems, cysts, any medical diagnoses, etc. If nothing, put N/A.

Current Medications given:

Please list all medications with dosages and list any supplements currently being used. If none, put N/A.

Other possible stressful experiences we need to be aware of:

List any accidents, injuries, surgeries, dental procedures your pet has had. Please describe them along with approximate dates/ages. If none, put N/A.

PET EMOTIONAL & BEHAVIORAL ASSESSMENT

My pet's personality:

Are they generally playful, fearful, worried, happy? What are their likes/dislikes? Fears and phobias? Please describe in full detail.

Other pet's in the home:

Name/breed/age of other pets in your home. If none, put N/A.

How were you referred to our practice?

When are you available for a $100 phone consultation (may take up to an hour) to get advice on how to help your pet's issues?

Please note that this consult is REQUIRED if you want to become a new patient. *CURRENT CLIENTS PLEASE DISREGARD THIS*

Monday AM

Monday PM

Tuesday AM

Tuesday PM

Wednesday AM

Wednesday PM

Friday AM

Friday PM

I am a current client

I understand that I need to call my conventional veterinarian to send records to SAAC. IMPORTANT: Clients with records will be contacted first.

We cannot set up an appointment until all records are sent. Email: sheppardanimalcare@gmail.com

Yes

Thank you for your submission!

New Patient Form