NEW CLIENT INTAKE FORM

Welcome to Revitalizing Pet Care. We promise to take very good care of you.

This form collects your basic information so we can set up your client and pet file in our system. It helps us get everything ready behind the scenes before your onboarding call.

New Client Information

First Name *

Last Name *

Email *

Your Phone *

Preferred Contact Method *

Phone

Text/SMS

Email

Address *

Street Address

City

State

Postal code

Former Client

I have been a former client of Dr. Pam’s.

When did you last see us?

Add Secondary Contact

Secondary Contact *

If someone else helps with your pet’s care or may need to be contacted about appointments or decisions, please list their name above.

Secondary Contact Phone *

Your Goals

What would you like to discuss or address during our appointment? *

Current Vet Care

Traditional Vet Name *

Clinic Name *

Clinic Phone Number *

Alternative Therapies

Pet Details

Do you have Pet Insurance? *

Yes

No

For those who maintain pet insurance, we provide the records to the owners for submission.

Pet's Name *

Species *

Dog

Cat

Breed *

Color *

DOB/Age *

Sex *

Male

Female

Spayed/Neutered/OSS/Vasectomy *

Yes

No

Additional Comments or Medical History

Add Another Pet?

Do you have any more pets you would like to register at this time? *

No

Yes, Add a Pet

Signature & Acknowledgements

Cancellation Policy

Appointments must be changed or canceled at least 24 business hours in advance. Late cancellations are charged 75% of the appointment fee. Cancellations made within 2 hours or missed appointments are charged the full fee. To cancel a Monday 9 a.m. appointment, notice must be received by Thursday 9 a.m. (office closed Fridays). Once scheduled, it’s the client’s responsibility to maintain, change, or cancel appointments.

Acknowledgement

I understand that acupuncture, chiropractic, herbology, homeopathy, whole food nutrition and other holistic modalities are considered alternative therapies by the Texas State Board of Veterinary Medical Examiners. I also understand that Dr. Pam will inform me of conventional treatments available and their probability to cure the problem.ailable and their probability to cure the problem.nderstand that Dr. Pam will inform me of conventional treatments available and their probability to cure the problem.ailable and their probability to cure the problem.

Pet Media

By checking this box, I allow Dr. Pam Montgomery-Fittz the right to take photographs or video of my animal/s. I authorize Dr. Pam to use and publish these in print or electronically and agree that Dr. Pam may use such images with or without my name and for any lawful purpose including publicity, illustration, advertising or web/online content, social media, webinars, etc.

Agreement

Your Agreement *

I read and understand and agree to both the cancellation policy and acknowledgement as written above.

By checking this box, I consent to receive messages from Revitalizing Pet Care related to my appointments, account, orders, or services.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others.

Signature *

Clear

Please sign here

Woo hoo! Now you're ready for the Pet History Form:

GO TO THE PET HISTORY FORM

214.991.2240

454 Houston Street Coppell, TX‍

The information provided at this site has not been evaluated by the US Food and Drug Administration and is for educational purposes only.
It is not intended as a diagnosis, treatment, or prescription for any diseases.