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Contact Us/Canine Health History Form

We will respond to forms submitted after Friday, 4:00pm on the following Monday.

Owner's Full Name*
Dog's Name and Breed*
Address*
City* State* ZIP*
Phone* Email*
Dog's Date of Birth*
     
Dog's Veterinarian* Vet Phone Number
 
 
 
 
Who may we thank for referring you?
 
Reason for this consultation?*
 
When did this condition start? How did it start? Is it getting worse?
What seems to make it better? What seems to make it worse?*
 
Please list any major veterinary visits or hospitalizations.
 
Please list any medications your dog is taking.
 
Please list any herbs, vitamins or nutritional products your dog is taking.
Also, please list the brand and type of food you give your dog.
 
By submitting this form, I affirm that I have answered this questionnaire to the best of my recollection and knowledge, and I hereby request and consent to consultation, acupuncture and other procedures associated with Traditional Chinese Medicine from Jeanie Marie Kraft, L.Ac. of Four Paws Acupuncture for my dog.
 

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