Standard Consult Patient Intake "*" indicates required fields Appointment Time Preference* Any 10am-Noon Noon-2pm 2pm-5pm About You and Your PetIf you have multiple pets, please complete one form for each. Please do not combine information onto a single intake form. Your Name* First Last Spouse/Partner Nameenter if you would like both names on the chart First Last Your Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How May We Reach You?Preferred Method of Contact* Phone Email Text Your Email Address* Your Phone*Best Time to Call You*Your Pet's Name*If you have multiple pets, please complete one form for each. Please do not combine information onto a single intake form.Species* Canine Feline Breed*Age or Birthdate*Sex* Female Intact Female Spayed Male Intact Male Neutered The primary purpose for requesting this appointment type My pet is generally healthy and I am wanting a holistic approach I am seeking approval for therapeutic modalities for my pet Reason for visit or current concerns*Please tell us a little about what is going on (more details may be added below)Please list past or previous health issues, types of symptoms seen and approximate dates/years affected.*Any treatments (holistic or conventional) or surgeries in past twelve months.*Please list current prescription medications or supplements.*Describe your pet's activity level -and- how often he/she exercises.*Please provide clinic names AND phone numbers* of veterinarians (general practice or specialists) that your pet has seen in the past 3 years.**or any references we need to obtain medical records which you consider pertinent for Dr. Kangas to review your pet's medical history. *International clients, please also provide an email address of any attending veterinarians.What are you currently feeding your pet and how often? Please provide 1) Brand and name of food being given, 2) Frequency of feeding, 3) Amount being offered at each feeding*How did you find us?*i.e. Google search, pet health podcast or live event, referral from friend or family member, referral from veterinarian. other.Please submit a photo of your pet*ensure a clear face viewMax. file size: 256 MB. Anything else you would like to share?I understand and agree to the Informed Consent*Integrative Veterinary Care (IVC) provides health consultations, physical examinations, and alternative treatment options for your pet. IVC does not provide emergency or urgent care services. We encourage all clients to have their pets established with a primary care veterinarian and / or utilize urgent care or emergency service veterinary hospitals for these circumstances. The initial consultation with Dr. Kangas is 60 minutes in length. Follow up appointments are 30 minutes in length. If your appointment runs over time, and if the Doctor is available to continue the conversation (at her discretion), you agree to an additional run-over fee of $120 for up to an additional 15 minutes. Dr. Kangas and associate practitioners of IVC utilize multiple holistic, complementary and alternative modalities as an adjunct to your pet’s healthcare. These treatments may include acupuncture, chiropractic care, laser therapy, ozone therapy, massage therapy and healing touch modalities. These modalities are distinct from traditional western veterinary care. IVC will explain the benefits and any risks associated with these modalities. All medications and supplements are non-returnable/non-refundable. Informed Consent Payment Policy*Integrative Veterinary Care (IVC) does not require payment at the time of scheduling. For virtual/telehealth appointments we do require a payment method on file for all virtual appointment types. A member of the IVC team will reach out to you approximately two weeks prior to your appointment to verbally collect your credit card information and you will be billed/charged on the day of your appointment or in the event your appointment is cancelled in accordance with our cancellation policy (see below). A 3% card processing surcharge is added to all invoice totals. To avoid the surcharge, payment may be made by Zelle. For in-person appointments, you have the option to pay with cash or if using a debit or credit card, a 3% card processing surcharge will be added to the invoice total. Care Credit is accepted for in-person appointments only. I agree to the payment policy Cancellation Policy*We value your time and ask that you respect ours by providing advance notice if you need to cancel your appointment. This gives us the opportunity to help as many animals as possible, in rebooking that time. If you need to cancel within less than 24 hours’ notice (and is not an emergency), there may be a 50% cancellation fee of the posted/quoted appointment price. By submitting this form, you acknowledge informed consent and agree to the terms of the cancellation policy. I agree to the Cancellation Policy Date*
