New Client Information Form

Our COVID-19 Safety Policies

Due to the COVID-19 crisis Dr. Mathis is trying to see most patients outside. Masks and social distancing are required. If this is not possible you need to let her know. By scheduling an appointment you are acknowledging that no one in your household is showing any COVID-19 symptoms and assuming the risks associated with COVID-19. You must inform Dr. Mathis before your appointment if this changes.

Client Contact Information
Owner Name*
First Last
Spouse
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone
Email*
Employment Information
Employer
Occupation
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone Number
Veterinarian History
Who referred you to us?
Regular Veterinarian
Veterinarian Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Pet/Patient Information
Pet Name*
Pet Breed*
Pet Birthdate*
Pet Sex*
Pet Species*
- Dog
- Cat
- Rabbit
What is your primary concern for Dr. Mathis today?*
Consent*
Dr. Mathis is an alternative veterinary practitioner. She practices Traditional Chinese Medicine (TCM), acupuncture, western herbal medicine, Naumbudripad Allergy Elimination Technique (NAET), diet, nutritional and behavioral consulting. She will happily discuss traditional western medical choices with you, but western treatments will be referred back to your regular veterinarian. Though alternative medicine has been in use for thousands of years, there has not been extensive western research proving its efficacy in every case, and it is considered experimental treatment by some. Dr. Mathis will make every effort to keep your pet comfortable and safe, but animals, like people, can have unexpected reactions to any treatment and this needs to be accepted as a possibility. Also, there is no guarantee that treatment will be effective. You have read the above and understand that alternative treatment may be used on your pet and you accept responsibility for this decision.
Payment in full by check or cash is due after each visit.
Comments
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New Client Information Form

Our COVID-19 Safety Policies

Client Contact Information

Employment Information

Veterinarian History

Pet/Patient Information

Contact Us

House Calls