New Patient Form: Integrative Medicine and Rehabilitative Therapy

Owner first name(s)

Owner last name

Email

Primary Phone Number

Secondary Phone Number (optional)

How would you like to receive information or communication from us?

Text

Email

Phone call

No preference

Your address:

Multi-line address

Country/Region

Address

City

Zip / Postal code

From which veterinary clinic(s) can we request your pet's medical records?

Do you authorize Red Sage to contact the above veterinary clinic(s) to obtain your pet's medical records?

Yes

No

Would you like us to share your Red Sage medical records with the above veterinarian?

Yes

No

Do you have pet insurance? If so, which company?

Pet's Name

Pet's Breed

Pet's date of birth or approximate age

Male or Female? Spayed/Neutered?

Scheduling Preferences: Please provide us with some preferred days + times for appointments. Our schedule books in advance, so we cannot guarantee availability but we will do our best! Our doctors generally see appointments between 9am and 3pm Mon- Fri.

Is there a Red Sage practitioner you know or prefer to work with? Or first available?

What is the primary concern/injury/issue you are seeking treatment for at Red Sage?

What diagnostics or work-up (x-rays, blood work, MRI, etc) have been done related to this or similar issues? Where were these performed?

How long has your pet been dealing with this condition? Is the condition getting better, worse or stable?

What interventions have been helpful in treating this condition? What interventions have been unhelpful or minimally helpful in treating this condition?

What are the signs of pain that your pet shows? (E.g. limping, yelping, difficulty rising, difficulty getting around)

Has your pet experienced any previous health issues?

How has this condition impacted your pet’s overall quality of life? (E.g. mood, playfulness, sleep patterns, appetite, interaction with your family)

Do you have a specific goal for treatment at Red Sage?

Please provide a detailed list of your pet's medications and supplements, including frequency and dosing. (e.g. Rimadyl 50mg twice daily for the last 2 months)

Please provide a detailed list of your pet’s diet and food intake. (E.g. Nulo Front Runner Small Breed ¾ cups twice daily topped with green beans, dried liver treats and a rawhide chew twice weekly)

In human medicine, Patient-Centered Care is a model in which the patient (or in this case, you the pet’s person) has an important role in guiding the framework of therapy. This is the way we practice at Red Sage, we truly see it as a partnership with you and your pet. It is important for us to know your vision for medical care in order to maximize your experience.

Often our treatment plans include some home care- how much time per week do you have to work with your pet?

The finances of veterinary care can often be a source of stress for pet owners. This is an aspect of care that we like to discuss openly and address very transparently at Red Sage.

Does budget play a significant role in your treatment decisions and if so, do you have a weekly or monthly budget to help us with treatment planning?

Are there specific therapies within the realm of what Red Sage offers that interest you in particular?

Is there anything else you would like us to know about your pet? (E.g. allergies, fears, loves/preferences, commands, etc.)

Please add any additional comments, concerns or information that you would like your veterinary team to know. (Optional)

Are you comfortable with your pet's picture or story being shared with others via social media or our website?

YES

NO

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