TCVM Intake and Questionnaire

Which CRCG location are you visiting?

CRCG Broomfield
CRCG Englewood

Client Information

Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Email*

Today's Date

Mobile Phone*

Home Phone

Work Phone

Other Guardian Name

First Last

Pet Information

Pet Name*

First Name

Breed*

Date of Birth (if unknown, see next question)

If the DOB is unknown, what is your pet's estimated age?

Family Veterinarian Name*

Clinic Name*

Rabies/Distemper Expiration

Sex*

Male
Female

Spay/Neuter*

Yes
No

Current Health Information

How did you hear about us?*

Friend
Vet
Other Dog Healthcare Provider
Promotion
Web search
Advertising
Other

Details

Do we have your permission to add you to our CRCG newsletter mailing list?*

Yes
No

ie: Monthly specials, Holiday theme parties, fundraisers, contests, game days, etc. (Note: CRCG does not share or sell your contact information. All information is confidential.)

How would you like to be contacted with appointment reminders?*

Additional Pets

Do you have any additional pets?

Pet Name

First Name

Breed

Date of Birth

Sex

Male
Female

Spay/Neuter

Yes
No

Rabies/Distemper Vaccination Expiration Date

Details

Please note if this dog is under any treatment provided by a vet or if there are health problems or concerns of which you would like us to be aware.

Liability Agreement

Please select the checkboxes to indicate you have read and understood the information provided.

I understand and agree that in admitting my dog to the use of its facility, CRCG has relied on my representation that my dog is in good health or I have disclosed any known health issues.

I have documented any issues in the past of harm, aggression or threatening behavior towards any person or any other dog.

I understand and agree that the staff of CRCG is not engaged in the practice of general veterinary medicine.

I understand and agree that CRCG, its staff and volunteers, will not be liable for any problems that arise out of my or my dog’s use of CRCG’s facilities and I hereby release them from liability of any kind whatsoever in regards to my dog(s) attendance and participation at CRCG.

I understand that I am solely responsible for any harm caused by my dog(s) while my dog is utilizing the facilities of CRCG. This includes any harm to persons and/or other dogs as well as to the physical property of CRCG.

I understand and agree that any problems that develop with my dog will be treated as deemed best by the staff and volunteers of CRCG, in their sole discretion. I assume full financial responsibility for any and all and all expenses involved including injuries to persons and/or dogs, and damages to the facility.

I understand that if an injury caused by my dog or to my dog will only be treated if it is considered to be of a serious nature as determined by CRCG staff in its sole discretion. In the event that treatment is administered, I accept full responsibility for financial obligation of treatment to my dog and any dog injured as a result of my dog’s behavior.

I understand that I am responsible for paying 100% of the cost of a scheduled appointment if I cancel with less than 48 hours notice.

Package refund requests will be calculated by charging the full price for the services used.

I have reviewed and selected the above conditions of the liability agreement. CRCG will be unable to treat my pet if the liability agreement is not completed prior to my first appointment.*

Yes

Photo Release

I grant to CRCG, its representatives and employees the right to take photographs of me and my dog in connection with any CRCG services. I authorize CRCG, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that CRCG may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.*

Yes
No

I agree that there are inherent risks to me associated with use of the CRCG facilities arising out of or associated with use and conditions, such as swimming, wet floors, exercise mats, and other dogs. In consideration for CRCG granting me permission to use these facilities, I agree to release CRCG from liability arising out of or associated with such use, and hereafter waive any and all claims which may arise out of or be associated with such permissive use of the CRCG facilities.*

Owner's Name Date

I certify that I have read and understand this Agreement and that the information set forth above is true and correct. I agree to accept all the terms, conditions, and statements of this agreement, and any rules or regulations of CRCG.

What are you hoping Traditional Chinese Veterinary Medicine will accomplish for your pet?*

What is your pet's energy level?*

Is your pet's appetite:*

Normal
Decreased
Increased

Are your dog's stools:*

Normal
Abnormal

If your dog's stools are abnormal, describe what they look like.

Is your pet coughing?*

Yes
No

If your pet is coughing, describe the cough.

Is your pet sneezing?*

Yes
No

Is your pet vomiting?*

Yes
No

Is your pet's water intake:*

Normal
Increased
Decreased

Is your pet's urination:*

Normal
Increased amount
Decreased amount
Bloody

Is your pet:*

Heat seeking
Warm seeking
Neutral

Does your pet sleep through the night?*

Yes
No

If not, describe what happens.

Describe your pet's behavior around stranger pets.*

Describe your pet's behavior around humans.*

Is your pet itchy?*

Yes
No

If yes, where?

Is your pet reactive to loud noises?*

Yes
No

Is your pet reactive to sudden movement?*

Yes
No

Does your pet have a history of seizures?*

Yes
No

Does your pet have a history of heart disease?*

Yes
No

What is your pet's diet?*

What medication(s) is/are your pet taking?*

What supplements is/are your pet taking?*

Phone

This field is for validation purposes and should be left unchanged.