Patient Update – IntVetCare.com

IVC Patient Update

"*" indicates required fields

So that Dr. Kangas may best prepare for your consultation, please complete and submit the information below. Notes: All questions require a response, if the answer is no or none, please simply type NONE or N/A in the prompt. Average time to complete is 3-5 minutes. Please be sure to have a photo of your pet available to upload.

Your Name*

First Last

Spouse/Partner/Significant Other (that you would like on record)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Your Phone*

Your Email*

Your Pet's Name*

What are your current concerns or symptoms you wish to address?*

Please provide clinic name and phone number of Veterinarian(s) - General Practice/Specialist your pet has seen in the past 12 months*

Please list all prescribed medications and their related doses that your pet currently take*

please include heartworm and/or flea/tick prevention

Please list all supplements and their related doses that your pet currently take*

Has your pet received any vaccines in the past year?*

if yes, please list vaccine and date given

Please share information your pet's current diet*

Has there been any major changes in the pet's household environment (moving, marriage, death of other pet or human, divorce, new pet)?*

Please submit a current photo of your pet*

Max. file size: 256 MB.

ensure a clear face view

PLEASE READ AND SIGN BELOW:

I authorize Integrative Veterinary Care practitioners to treat my pet: (Please sign or initial below)

Signature

Entry Date*

IVC Patient Update

PLEASE READ AND SIGN BELOW:

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