New Client Form - Chattanooga Holistic Animal Institute

Name(Required)

First Last

Phone(Required)

Cell Phone

Email(Required)

Address

Street Address Address Line 2 City State ZIP Code

Would You Like to Add Anyone Else to This Account?(Required)

Yes

Additional Person’s Name(Required)

Additional Person’s Phone(Required)

Preferred Method of Contact?(Required)

How did you hear about CHAI?

Who is your regular vet?(Required)

May we use a photo/video of your animal (no names will be used) on our social media?(Required)

Yes

Our Policies

Opening an account: To open an account with us, you must be at least 18 years of age.(Required)

I Understand

Payment Policy: Payment is due at time of service. We accept cash, credit cards, and CareCredit.(Required)

I Understand

Cancellation Policy: Please notify us as soon as possible if you need to reschedule an appointment. A 24 Hour cancellation notice is required to avoid a no show fee of $68.00(Required)

I Understand

Late Arrivals: Arriving late to appointments may result in fees. Repeated late arrivals could lead to dismissal.(Required)

I Understand

Code of Conduct: We aim to be respectful and professional with clients and expect the same in return.(Required)

I Understand

Aggressive Animals: Unfortunately we cannot accept patients who exhibit aggressive biting behavior that endangers our staff.(Required)

I Understand

Communication Policy: How and when to contact us for medical questions, prescription refills and scheduling.(Required)

I Understand

Provide Your Signature Here(Required)

Pet Information

Pet Name(Required)

Age or Birthday(Required)

Species(Required)

Breed(Required)

Color(Required)

Markings(Required)

Gender(Required)

Is your pet Spayed/Neutered?(Required)

Is your pet known to bite?(Required)

Known Medical Conditions(Required)

Current Medications(Required)

Has your pet ever had a reaction to vaccines, foods, medications or anesthesia?(Required)

Yes

Is your pet experiencing any health or behavioral issues you'd like to address?(Required)

Yes

What symptom that your pet is having are you most concerned about?(Required)

When did you first notice the symptom or issue?(Required)

Please list any other current issues:(Required)

Please list any previous, major health concerns:(Required)

Please describe your pet's diet in detail:(Required)

Add a second pet?

Yes

Pet #2

Pet Name(Required)

Age or Birthday(Required)

Species(Required)

Breed(Required)

Color(Required)

Markings(Required)

Gender(Required)

Is your pet Spayed/Neutered?(Required)

Is your pet known to bite?(Required)

Known Medical Conditions(Required)

Current Medications(Required)

Has your pet ever had a reaction to vaccines, foods, medications or anesthesia?(Required)

Yes

Is your pet experiencing any health or behavioral issues you'd like to address?(Required)

Yes

What symptom that your pet is having are you most concerned about?(Required)

When did you first notice the symptom or issue?(Required)

Please list any other current issues:(Required)

Please list any previous, major health concerns:(Required)

Please describe your pet's diet in detail:(Required)

Add a third pet?(Required)

Yes

Pet #3

Pet Name(Required)

Age or Birthday(Required)

Species(Required)

Breed(Required)

Color(Required)

Markings(Required)

Gender(Required)

Is your pet Spayed/Neutered?(Required)

Is your pet known to bite?(Required)

Known Medical Conditions(Required)

Current Medications(Required)

Has your pet ever had a reaction to vaccines, foods, medications or anesthesia?(Required)

Yes

Is your pet experiencing any health or behavioral issues you'd like to address?(Required)

Yes

What symptom that your pet is having are you most concerned about?(Required)

When did you first notice the symptom or issue?(Required)

Please list any other current issues:(Required)

Please describe your pet's diet in detail:(Required)

Add a fourth pet?(Required)

Yes

Pet #4

Pet Name(Required)

Age or Birthday(Required)

Species(Required)

Breed(Required)

Color(Required)

Markings(Required)

Gender(Required)

Is your pet Spayed/Neutered?(Required)

Is your pet known to bite?(Required)

Known Medical Conditions(Required)

Current Medications(Required)

Has your pet ever had a reaction to vaccines, foods, medications or anesthesia?(Required)

Yes

Is your pet experiencing any health or behavioral issues you'd like to address?(Required)

Yes

What symptom that your pet is having are you most concerned about?(Required)

When did you first notice the symptom or issue?(Required)

Please list any other current issues:(Required)

Please describe your pet's diet in detail:(Required)

Add a fifth pet?(Required)

Yes

Pet #5

Pet Name(Required)

Age or Birthday(Required)

Species(Required)

Breed(Required)

Color(Required)

Markings(Required)

Gender(Required)

Is your pet Spayed/Neutered?(Required)

Is your pet known to bite?(Required)

Known Medical Conditions(Required)

Current Medications(Required)

Has your pet ever had a reaction to vaccines, foods, medications or anesthesia?(Required)

Yes

Is your pet experiencing any health or behavioral issues you'd like to address?(Required)

Yes

What symptom that your pet is having are you most concerned about?(Required)

When did you first notice the symptom or issue?(Required)

Please list any other current issues:(Required)

Please describe your pet's diet in detail:(Required)

We understand that every pet is unique and we love that! Please pick one of the following statements that best describes your pet to help us get to know them:(Required)

Easy going, loves everyone, laid back, easily satisfied, patient, social, slow reaction to strangers.

Fearful, quiet, independent, one person pet, shy, smart, runs away from strangers.

Well-behaved, obedient, likes a routine, problem solver, ignores strangers.

Dominant, very active, moves fast, competitive, stubborn, becomes upset when they do not get their way, barks at strangers.

Excitable, hard to calm down, likes to be the center of attention, mischievous, wags tail for strangers.

Please check all boxes that best describe your pet:

Decreased appetite

Increased appetite

Vomiting

Diarrhea

Constipation

Increased thirst

Decreased thirst

Lumps on body

Urinary incontinence

Itchy skin

Ear issues

Back pain

Limping

Weight loss

Coughing

Sneezing

Vision problems

Hearing problems

Fatigue/lethargy

Oral or dental issues

Dry/flaky skin

Oily/greasy skin

Pet prefers to sleep in warm/sunny

Pet prefers to sleep in cool/shady

Painful

Restless or trouble sleeping at night

Pants when resting

Blood in urine

Behavioral problems

If painful, where?(Required)