Veterinarian form | Dr Signe Beebe | Online Integrative Veterinary Consultations

Please fill out this form before your call with Dr. Beebe.

VETERINARIAN-PATIENT REGISTRATION

First name

Last name

Practice Name

Practice Website URL

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Pet's name

Species

Dog

Cat

Other

Breed

Pet's age

Male Intact

Female Intact

Male Neutered

Female Spayed

Color

DIET

What type of diet is the pet eating? (be specific – raw, dry, wet, home-made, prescription)

How long has the owner been feeding this diet?

How many times per day do you feed your pet?

What is the name of the brand if purchased? What is the protein (fish, beef, chicken, lamb etc)?

DIAGNOSIS

Reason for consultation; please give both the conventional and Chinese medicine diagnosis if known

When did the problem(s) start?

For TCVM practitioners, what is the current tongue and pulse diagnosis?

Has the problem/condition improved on conventional drug therapy, acupuncture, herbal medications or other therapies you have used?

What are your goals working with Dr Beebe?

How did you hear about us?

CURRENT MEDICATIONS, HERBAL FORMULAS AND SUPPLEMENTS

What medication(s) have you prescribed for this pet

What is the dose (in mg)?

How many times a day are they given?

Date began giving the medication?

What supplements (vitamins-minerals, herbs, homeopathics, others) have been prescribed and why?

\How long have you prescribed the current supplements?

Does the pet have any known medication allergies?

MEDICAL RECORDS, LABORATORY AND OR OTHER DIAGNOSTIC REPORTS

Please email all medical records (SOAP) and reports from the last 12 months for a comprehensive and accurate evaluation of your case. Include any and all histopathology reports for all patients.

By signing this form, I understand the following:

A variety of alternative and integrative method/options for veterinary care are available depending on the condition of the individual patient. Dr. Signe Beebe is consulting on alternative and integrative methods of treatment including, but not limited to, acupuncture, Chinese herbs, Chinese food therapy, intravenous vitamin C, prolotherapy, neural therapy, gold wire implantation, veterinary Tuina, laser therapy, ozone, microbiome restoration, veterinary manipulative therapy (chiropractic), ozone therapy and nutritional supplements, some of which may or may not be recognized as standard methods of treatment by the American Veterinary Medical Association (AVMA) as well as conventional medicine.
I understand that recommendations for the treatment of all pets are in accordance with prevailing standards of competency in the above-described modalities of treatment as recognized by the AVMA, American Academy of Veterinary Acupuncture, the International Veterinary Acupuncture Society, the Chi University of Traditional Chinese Veterinary Medicine, the American Holistic Veterinary Medicine Association, The Veterinary Botanical Medicine Association and the American College of Veterinary Botanical Medicine. No guarantee or assurance has been made as to the result that may be obtained from the advice given.
A written report can be requested and provided within 5 business days of the initial consultation.
Consulting Fees: Are payable 3 business days prior to the consultation or recheck
Cancellation Policy: Please reschedule or cancel your consultation a minimum of 48 hours prior to your scheduled time. If you cancel in less than 48 hours, a cancellation fee may apply. (Please sign below)

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