they Appetite: up

Owner Name *

First

Last

Email *

Phone *

Patient Name *

Breed: *

Color: *

Age: *

Sex: *

Male
Female

Major complaint: *

When did symptoms start and how have they changed? *

What treatments have been used for this condition? *

Things that change the condition (better or worse during day/night, hot/cold climate, certain times of day, etc.) *

Has your dog ever received acupuncture before? *

Yes
No

Which does your dog prefer? *

AC/cool location
Sunny/warm location
No preference

Diet: *

Thirst: *

Oftern thirsty
Less thirsty
Not sure

Appetite: *

Ravenous
Finicky
Neither

Feces: *

Dry, bloody, or malodorous
Loose/diarrhea
Normal
Not sure

Urine: *

Short stream, malodorous, bloody
Long, clear streams
Normal
Not sure

Current medications or supplements: *

History of vaccination reaction? *

Yes
No
Unsure

Recent Behavior Changes (select all that apply) *

Exercise: *

5+ hrs/week
Less than 5 hrs/week
Intermittent or up to 1 hr/week
None

Behavior associated with exercise: *

Stiff before
Stiff after
None

Personality: Please select the description that best fits your dog. Can pick up to 2. *

Wood- aggressive, takes charge, no patience, very excitable, irritable
Fire- very friendly, playful, no patience, easily excited, vocal
Earth- OK with others, easy going, patient, not easily excitable, mellow
Metal- aloof, cooperative, patient, not very excitable, rule follower
Water- timid, runs away, patient, not excitable, insecure

Which describes your dog? *

Hyperactive, outgoing, confident
Quiet, timid, less confident

I, give consent to Dr. Mikaela Roicki to perform alternative medicine (acupuncture, herbs, holistic medicine, etc.) for the treatment of my animal. I understand the possible risks of alternative medicine. I have had the opportunity to discuss the details of treatment, alternative and conventional, with Dr. Mikaela Roicki, and had all inquiries answered satisfactorily.

I understand that alternative medicine can only be performed by a licensed veterinarian. I understand that such methods are not a replacement of conventional medicine, and that routine veterinary care (vaccines, deworming, annual exams, etc.) must be continued.

I understand that if an adverse reaction to treatment occurs, I have the right to contact the Texas Board of Veterinary Medical Examiners for investigation of Dr. Mikaela Roicki’s clinical capabilities and quality of care performed during each treatment.

By signing below, I voluntarily express consent to treatment(s).

Owner's Signature: *

Clear Signature

Date *

WE’VE MOVED. Our new address is 875 S. HEWITT DR., SUITE A, HEWITT, TX 76643

Canine Questionnaire and Consent Form

Canine Questionnaire and Consent Form

We proudly serve the pets in Hewitt, TX and beyond.

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