Jeane’s holistics

This form MUST be physically signed at the bottom NOT typed - and faxed, emailed or snail mailed
back to us PRIOR to your consultation
Name: _______________________________________________________________ Email Address: ________________________________________________________Dog's Name: __________________________________________ Breed of Dog: _______________________________________ Age of Dog _______Weight of Dog: ___________________ Gender (Male or Female?) ____________ Spayed, Neutered Or Intact? ___________Was there any noticeable physical or emotional change in your pet after being spayed or neutered? If yes, explain__________________________________________________ Has your pet ever been pregnant? Y__ or N__ If yes, when_________________________How many litters___________________________ Where did you obtain your pet? (ie, breeder, shelter, rescue, etc.)____________________________________________________________________ What age was your dog when they came to live with you and how long have you had him or her? _________________________________________________________________ Date Of Last Vaccinations? ___________ Vaccinated for: _______________________ How often is your pet vaccinated and which vaccines do they receive? _______________________________________________________________________ Is your pet micro-chipped? Y__ or N __ If yes, when______________________________ General health condition (skin, hair/coat condition, eyes - clear of any discharge or is there a discharge from time to time or every morning? normal stools or loose? lethargic or energetic? etc.) ________________________________________________________________________________________________________________________________ _______________________________________________________________________
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Please attach or email a recent photo of pet if possible.
Has the animal been diagnosed by a veterinarian with any illness or health problems? Also include any past or recent surgeries. Please list all diagnoses and how long problems have been on going as well as any symptoms still persisting: _______________________________________________________________________ _____________________________________________________________________________________________________________________________________________ Is She/He Currently On Any Medications (include any recent courses of steroids or
antibiotics)? If on prescription medications, what were they prescribed for and how long has he/she been on them? Have there been changes observed since being on the medications? If so, please list: _______________________________________________________________________ ______________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________ Is your dog on any parasite preventions (Heartguard, Frontline, Ivermectin, Advantage,
Mycodex, etc)? Which ones and for how long? _______________________________________________________________________ _______________________________________________________________________________________________________________________________________________ Does your pet exhibit any of the following physical conditions? (please explain any yes answer) Y__N__ Eye Infections/Drainage-irritation Y__ N__ Skeletal Abnormalities(hip dysplasia, etc) Other/explain: ___________________________________________________________ _______________________________________________________________________Does your pet exhibit any of the following temperament/behavior problems? (Please explain any Yes answer) Y__N__ Aggressive behavior (towards you or other animals)Y__N__ Dominance Issues Y__ N__ Compulsive Behavior (explain below)Other/explain:____________________________________________________________ _______________________________________________________________________
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Describe your pet's current Life Style. Example would be: how much exercise, how long
out of doors (if at all), home alone during the day, where the pet sleeps, interactions with
other pets people, favorite toy, favorite pastime, etc. Be as detailed as possible. _______________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ _______________________________________________________________________ Current Diet please include as much information as possible such as brand name of food,
the amount of food the dog gets at each feeding and how many feedings a day, how long has
the dog been on this particular food and what was the dog eating before the current diet? _______________________________________________________________________ ______________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________ How many times have you switched dog food and what brands? _______________________________________________________________________ ______________________________________________________________________________________________________________________________________________ List names of all supplements, vitamins and any other foods, table scraps or treats you are giving the dog. (List everything please). How many treats (estimate) does the dog get in a
______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ What brand of laundry soap, floor and/or counter cleaners do you use? ______________________________________________________________________________________________________________________________________________ Do you use air fresheners or burn scented candles? Yes____ No ____If yes, which ones and how often? ____________________________________________ What cleaning products do you use in your home? For floors, furniture, air fresheners,
etc? ___________________________________________________________________What products do you use in your yard? Are pesticides used on the lawn? Chemical fertilizers? ______________________________________________________________
How did you find my service? _____________________________________________
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What are your top three main concerns for your dog?
1.
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Disclosure Statement
The purpose and general goal of the veterinary naturopathic consultation offered by Jeannie (Jeanette) Thomason, VND is to educate the client about their animals body systems in relation to function and ability pertaining to maintenance of overall homeostasis (balance) through the removal of various, and typically specific, obstacles to their health, this thereby encouraging their body's own natural healing processes. Jeannie Thomason, VND does not function as a traditional allopathic veterinarian by diagnosing disease, treating disease, or performing invasive procedures, nor do her services replace that of a traditional licensed The information offered by Jeannie Thomason, VND is intended to provide general guidance. Nothing on the web site or during a regular consultation constitutes traditional allopathic veterinary advice. Always consult with a licensed veterinarian before undertaking any course of treatment for your animal or changing treatments or medications your own veterinarian has already prescribed. This consultation will hopefully suggest additional options to think about, and other areas to explore, based on your pet's condition.
I, as a mature adult, have read the disclosure statement and understand its content and the limits of these services. I voluntarily seek these consulting services for my animal and assume full responsibility for this decision. By completing and submitting this form, this constitutes my legal signature and acceptance of the services offered by Jeannie Thomason, VND, which will stand for the initial consultation date, stated in this disclosure form and for all subsequent consultations occurring after this date.
On consultations, whether by email or phone, once you've received your consult, there are no refunds. Refunds are available only if you cancel prior to your appointment 24 hours in advance or prior to the agreed upon deadline delivery date of your email consult. Once you have received your consultation, similar to software sales, no refunds are available at that time.
This form MUST be physically signed, (NOT typed) - and faxed, emailed or snail mailed
back to me PRIOR to your consultation
I have read and agree with the Disclosure Statement: Signature: ______________________________________________________________Date: _______________________________ Please email this history/questionnaire to: info@thewholedog.org OR snail mail to:
Dr. Jeannie Thomason
P.O. Box 1637
Cottonwood, CA 96022
You will receive a PayPal request for payment from jeanniethomason@gmail.com Payment is required in advance of consult. Thank you, I look forward to working with you to help your dog live a long, healthy, happy life!

Source: http://www.thewholedog.org/TWDHealthConsultationForm.pdf