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*Please read the following DISCLAIMER before filling out your pet's profile.

Please complete each section in order to best assess what program we can recommend to you. All information will be maintained as strictly confidential.

Please ensure that all marked areas are filled out before submitting.

Personal Profile

Name of Animal:
*Name of Owners:
*Address 1:
Address 2:
*Postal/Zip Code:
*Telephone 1:
Telephone 2:
Date Of Birth:
Referring Veterinarian:
Date of Last Visit:
Reason For Visit:

Please list any other conditions:

Has your pet been treated with chronic antibiotic therapy?

Please list all current pharmaceutical drugs:

Please list all current vitamins, herbs, or food supplements:

Areas of Concern
Comments and areas of concern:  

Lifestyle Considerations:

Does your pet get regular exercise?

Instructions: Answer the statements below by checking the line which applies to the animal.

Pet Health Profile

Experiencing exercise intolerance
Congestion in sinuses and lungs, allergies, heaves
Breath polluted air, smoking household
Constipation and or hard stools, flatulence
Digestive problems
Kidney/Bladder problems
Heart/Circulation problems

Reproductive problems
Over weight/Under weight
Skin disorders, Fungus, Bacteria, Allergies
Foul Breath
Eye problem discharge/red
Ear brown discharge/yeast infections
Nail health/chipping

We appreciate the opportunity to discuss your problems and concerns. We wish to make it clear that our intent is not to diagnose or prescribe, but to offer recommendations and information to help you establish a healthy order in your animal's daily life. If you seek medical advice, please consult a veterinarian. If you are seeking ways to take responsibility for your animal's health and well being, we are happy to be of assistance.



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