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                                      WELLSPRING HOLISTIC VETERINARY CARE CLIENT DATA

                                   (Please download, fill out, and bring to your first appointment)

Pet Owner Name (last, first)________________________________________________________________

Address (street)___________________________(City)____________________

(State)______(Zip)_________

E-mail Address__________________________Phone______________________

Cell Phone _________________ Drivers License or SSN ____________________

 Work Phone Number______________________

Circle method of Payment::   Cash ,  Check,  (Please Note Credit Cards Not Accepted)

How did you hear about Wellspring?_________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

                                                      PET INFORMATION

Pet Name____________________________  

Date of Birth (month, day, year)__________________

Species _____________ Breed__________________  

Gender (male, female)__________________

Coat Color_______________       Neutered or Spayed? (Circle One):    Yes   No 

Current Diet (Be Specific, include # of feedings per day, time of feedings, and what is fed)__________________________________________________________________________

_________________________________________________________________________

Medical History- List Previous or Current Medical Problems, Surgeries, and Current Medications. (Include Heartworm preventative for dogs- type, & date of last test)

___________________________________________________________________________

___________________________________________________________________________

I, the undersigned, understand that I am requesting Holistic Veterinary Care ( Acupuncture, Chinese  Herbal Therapy )

 for my pet. I understand that Wellspring Holistic Veterinary Care will take every precaution in treatment but that there

is no guarantee of results, nor any warranty of cure. I understand that I am fully responsible for the cost of treatment and that payment is due at the time of service.

Signed_______________________________________ (Pet Owner)

 Date ________________