Eastern Medicine Consult Form

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Please list model and color

The veterinarian and medical team will use this number to communicate with you throughout the appointment


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Appointment Time*

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Species*


Do you need any refills today?*


Patient's Appetite*



Patient's Thirst*



Patient's Energy Level*



Has your pet been experiencing




Check all that apply

Five Elements Questionnaire

The ancient Chinese divided the natural world into five categories which represented all the indispensable and fundamental elements constituting the universe. This five-category system was called Wu Xing because Wu means five and Xing means movement, activity, action, category, or element – this system has been translated as the Five Elements. Traditional Chinese medical practitioners use the properties of the Five Elements and the relationship between them to explain medical problems.

Please check the boxes below that describe your pet to aid Dr. West in determining your pet’s eastern medicine diagnosis and therapeutic plan.

Fire – Normals






Please check all boxes that describe your pet
Fire – Abnormals






Please check the boxes that describe your pet
Wood – Normals







Please check all boxes that describe your pet
Wood – Abnormals








Please check all boxes that describe your pet
Earth – Normals






Please check all boxes that describe your pet
Earth – Abnormals








Please check all boxes that describe your pet
Water – Normals






Please check all boxes that describe your pet
Water – Abnormals







Please check all boxes that describe your pet
Metal – Normals






Please check all boxes that describe your pet
Metal – Abnormals






Please check all boxes that describe your pet
Consent*
Consent*
Consent*
Consent*


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What's Next

  • 1

    Call us or schedule an appointment online.

  • 2

    Meet with a doctor for an initial exam.

  • 3

    Put a plan together for your pet.

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