New Client Information Form -

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.

Phone

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New Client Information Form

Client Contact Information

Employment Information

Veterinarian History

Pet/Patient Information

Contact Us

Appointments

New Client Information Form

Client Contact Information

Employment Information

Veterinarian History

Pet/Patient Information

Contact Us

Appointments

Announcement