New Acupuncture Client Form

Name: Lake Hills Veterinary Clinic
Address: 5298 Osage Beach Parkway, Osage Beach, MO, 65065, United States
Telephone: 573-302-8100
Price range: $

Thank you for choosing Lake Hills Veterinary Clinic! Please fill out the form as completely and accurately as possible.

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New Acupuncture Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 573-302-8100 for a faster response.

Name(Required)

First Last

Phone(Required)

Email(Required)

Pet's Name(Required)

Who should we contact to make medical decisions today?(Required)

Owner (named above)

Someone else (specify below)

Name(Required)

First Last

Phone(Required)

Email(Required)

Reason for seeking/needing acupuncture: (check all that apply)(Required)

Health problems

Injury

Other

If other, please specify(Required)

Are there any concerns for the following: (check all that apply)

Eating/drinking

Weight loss/weight gain

Itching/scratching

Shaking head

Vomiting

Diarrhea

Urination issues

Excessive sleeping

Difficulty rising

Lameness/limping

Car sickness

Behavioral problem

Other

If other, please specify(Required)

How long has your pet been experiencing the above problem(s)?(Required)

Energy/Wellbeing

Any increase or decrease in activity level?(Required)

Increased

Decreased

No change

Energy is the highest:(Required)

Morning

Afternoon

Night

Consistent

Attitude/mood is best:(Required)

Morning

Afternoon

Night

Consistent

My pet is:(Required)

Outgoing

Shy

Aggressive

My pet prefers:(Required)

To be cool

To be warm

No preference

My pet’s sleep is:(Required)

Normal

Decreased

Increased

Restless at night

My pet’s dreams:(Required)

None

Vocalized

Running

Mobility

My pet’s mobility level:(Required)

Normal

Reduced

Increased

My pet’s mobility is best:(Required)

Morning

Afternoon

Evening

Night

Consistent

My pet has a specific area that is weak or lame (check all that apply):

Front right leg

Front left leg

Rear right leg

Rear left leg

Pain

Is your pet in pain?(Required)

Yes

If yes, for how long?(Required)

Where is the pain located?(Required)

After rest, my pet is:(Required)

Better

Worse

After exercise, my pet is:(Required)

Better

Worse

Time of day pain is best:(Required)

Morning

Afternoon

Night

Consistent

Nutrition/Digestion/Urinary

Have there been any changes in appetite:(Required)

Increased

Decreased

No change

My pet:(Required)

Loves to eat

Is not food motivated

Is picky

Any increase or decrease in water consumption:(Required)

Increased

Decreased

No change

My pet drinks water:(Required)

Frequent small sips

Large amounts at one time

Moderate

Any change in urination:(Required)

Increased

Decreased

Incontinent

Straining

Vocalizes

Any change in bowel movements:(Required)

Normal

Soft

Diarrhea

Hard or dry

Constipated

Incontinent

Does your pet have gas?(Required)

Yes

Vomiting?(Required)

None

Occasional

Couple of times a week

What kind of food do you feed your pet?(Required)

How much do you feed?(Required)

Free fed (food is offered always/whenever hungry)

Measured amount

Skin

My pet has (check all that apply):

Brittle nails

Dry pads

Dry skin with large flakes

Dry skin with small flakes

Is your pet itchy?(Required)

Yes

Has your pet’s coat changed?(Required)

Yes

Is your pet on any medications, including flea/tick or heartworm preventives?(Required)

Yes

Is your pet on any supplements/vitamins/herbs/essential oils?(Required)

Yes

I give Lake Hills Veterinary Clinic authorization to access veterinary records from previous hospitals as needed.(Required)

I have read and agree

I understand that financial responsibilities for services are rendered at the time of discharge.(Required)

I have read and understand

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Name

This field is for validation purposes and should be left unchanged.

Request An Appointment!

We look forward to seeing you and your furry friend soon! Call us to schedule your next appointment or use our online form.

Appointment

Contact Us

Use the form below, and we’ll get back to you as quickly as possible. If you need immediate assistance during business hours, call us at 573-302-8100. We are available for emergency phone consultations after hours. You can also call the 24 hr ER hospital Horton Discovery at 573-777-3609.

Address

5298 Osage Beach Parkway
Osage Beach, MO 65065

Hours

Monday 8am-6pm

Tuesday-Friday 8am-5pm

Saturday 8am-1pm

We are available for emergencies after hours (Mon-Sun)

Contact

573-302-8100
[email protected]

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Email *

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How can we help you? *

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