New Patient Form

New Patient Form

Please call 561-741-4041 to schedule an appointment prior to submitting or if you have any questions about the form.

Use the form below to submit your information to our Physical Rehabilitation & Integrative Medicine team. Fields marked in orange are required.


    Client Information
    Client's First Name:

    Client's Last Name:

    Date:

    Address:

    Email:

    Your Phone:

    Patient Information
    Patient's Name:

    Age/DOB:

    Breed:

    Gender:

    Spay/Neuter:

    Referring Veterinarian:

    Medications (concentration and frequency)

    Diet (brand, amount per day)

    Supplements (brand, amount per day)

    Reason for visit

    Appetite

    Vomiting/gas

    Thirst

    Stool

    If Abnormal, describe

    Cough

    Cool or warm preference

    Energy level

    Optional Information
    Express Additional Concerns

    Other medical history (please include approximate dates of diagnosis)

    Does your pet enjoy being in the water/swimming?

    Do you have access to a swimming pool?

    What aggravates the problem?

    What eases the problem?

    Is the problem/pain affected by time of day or activity?

    If yes, please explain:

    May your pet receive small treats during his/her visit? (If not, please bring appropriate treats for your pet.)

    What specific goals do you have for your pet? (For example: climb up 4 steps to the front door with minimal assistance, resume 30-minute jogs with me, return to competitive agility)

    Other Information
    Photo Consent

    Periodically, JPESC will take photographs of our patients for positive promotional purposes for the clinic that may include images/stories for our website, hard print, and social media sites. By initializing, you authorize us to use your pet's images for such promotion at our discretion.

    Sharing Consent

    I consent for any reviews or testimonials for JPESC that I post online to be reshared on the JPESC website and other social media platforms for JPESC marketing purposes.