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Let's Get You Onboarded!
Holistic Pet Health Coaching & Nutrition Client Intake Form.
Dogs Name
Breed(s):
Current Weight
Owner/Pet Parent's Name
Phone Number
Email Address
City
State
Zip Code
Veterinarian's Name
Veterinarian's Phone Number
Veterinarian's Address
Medical History
Is your dog currently under medical supervision?
Yes, they are
No, they are not
If YES, please provide details:
Please list any current or past medications:
(If the medication is no longer being administered, indicate how long your pet has been off the medication.)
Please list any known medical conditions your dog has been diagnosed with, past or present:
(e.g., seizure disorder, dysplasia, cancer, arthritis, diabetes, surgeries, etc.)
Is your dog current on vaccinations?
Yes, they are
No, they are not
If NO, please explain:
Is there any additional information about your dog’s health history that would be helpful for planning a safe and effective nutritional plan (including diet and supplements)?
What are your goals for this consultation?
Acknowledgment and Agreement
By clicking "I Agree" I understand that the consultation I am receiving for my pet is a suggestion for healthy food choices and lifestyle changes, which may include supplements. I acknowledge that as my pet’s guardian, I have voluntarily sought this consultation with my Certified Holistic Pet Health Coach.
I Agree
By clicking "I Agree" I further acknowledge that the suggestions provided by my Certified Holistic Pet Health Coach are not a substitute for veterinary examination, diagnosis, or treatment. I understand that I should consult a veterinarian or other qualified medical specialist for any medical concerns I may have.
I Agree
By clicking "I Agree" I understand that the Certified Holistic Pet Health Coach is not qualified to diagnose, prescribe medications, or treat any physical illness, and that nothing discussed during the consultation should be interpreted as such.
I Agree
By clicking "I Agree" I agree to keep Lori Gammon Megginson, Certified Holistic Pet Health Coach, informed of any changes in my pet’s medical profile. I understand that there shall be no liability on the part of the Practitioner should I fail to do so or fail to provide complete medical disclosure.
I Agree
By clicking "I Agree" I agree that The Peaceful Paw, LLC/Lori Gammon Megginson will not be liable for any adverse reactions or side effects from suggested supplements or dietary changes for my pet. I understand that any changes must be discussed with my veterinarian.
I Agree
Please Type Your Full Name As Your E-Signature
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