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This form MUST be physically signed at the bottom NOT typed - and faxed, emailed or snail mailed
back to us PRIOR to your consultation
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,
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.) ________________________________________________________________________________________________________________________________
________________________________________________________________________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)
_______________________________________________________________________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:____________________________________________________________
_______________________________________________________________________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. _______________________________________________________________________
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? _____________________________________________
What are your top three main concerns for your dog?
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: email@example.com OR snail mail to:Dr. Jeannie Thomason
P.O. Box 1637
Cottonwood, CA 96022
You will receive a PayPal request for payment from firstname.lastname@example.org
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!
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