CALL US: 719-633-7769

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CALL US: 719-633-7769

Home
About
Services
Resources
Contact
Call to book

Acupuncture Form

Save time during your acupuncture appointment. Complete your acupuncture form online from any device at any time before your visit.

Acupuncture Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pets before your acupuncture visit.

Owner Information

Name *

First

Last

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Email *

Phone *

Pet Information

Pet's Name *

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Species (dog, cat, etc.) *

Age/Date of Birth *

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Sex *

Male
Neutered Male
Female
Spayed Female

Breed *

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Color *

Weight *

Additional Information

Primary Care Veterinarian *

Were you referred? *

Yes
No

If you were referred, who may we thank? *

Has your pet been seen by any other veterinarians for this problem? *

Yes
No

Please list the practice name as well as the veterinarian below: *

Has your pet had any diagnostic imaging done for this problem? *

Yes
No

If diagnostic imaging was done, please tell us where: *

What are your primary reasons and goals for coming to Cook Veterinary Hospital? *

What does your pet eat? *

Please indicate kinds and forms, such as brand, primary protein source (Chicken, Fish, Beed, etc.) kibble, canned, etc., amount of food, include treats

Does your pet currently require assistance for normal activities? Please explain as much as possible. *

Walking, getting up, getting into car, positioning for urination and/or defecation, etc.

What is your pet’s current activity? *

Frequency and length of walks, etc.

What type of flooring do you have in your home? *

Is your pet slipping or having trouble getting up on slick surfaces such as hardwood/tile? *

Are there any stairs your pet much maneuver daily? If so, do they have difficulty? *

What supplements does your pet currently receive? Please include brands, amounts, etc. *

Examples: joint supplements, vitamins, fish oils, etc.

What medications does your pet receive? Please include brand and doses. *

Please include all prescribed and routine medications such as heartworm prevention, flea/tick prevention, etc.

Are there any time constraints that we should be aware of for the future for working with your pet? *

Signature *

Clear Signature

Date *

Website

Ready to Visit?

We proudly serve the pets of Manitou Springs, Colorado Springs, and the surrounding areas. We look forward to seeing you and your pet! Request an appointment by clicking the button below.

Questions?

We look forward to hearing from you.

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Location

21 W Cimarron St.
Colorado Springs, CO 80903

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Contact Information

Phone: 719-633-7769
Email: cookveterinary@gmail.com

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Hours

Mon, Wed & Fri: 7:30 AM – 6:00 PM
Tue: Appointment based
Thu: 7:30am – 6:00pm
Sat: 8:00am – 12:30pm
Sun: Closed

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