Healing Center for Animals

Client Questionnaire

Below please find our Client Questionnaire. The questionnaire is designed to get additional information beyond the routine medical history and laboratory results for your animal. You have two options:

1. Fill out the online questionnaire below. Also fax us (203-222-0926) the diagnostics and blood test results from your veterinarian.

2. Print and fill out the PDF version (printable version of the client questionnaire) and fax it (203 222-0926) with the diagnostics and blood test results from your veterinarian.

Upon completion of either option, please call 203-227-4943 to confirm receipt by our customer service department and set up a consultation with Dr. Robert Goldstein.

*You will be asked for your credit card information at the time of your call. Thank You.


Please fill in all fields so we can help you & your pet better.
WARNING: Speak with your Veterinarian before vaccinating your pet. If they suffer from a compromised immune system or are in a fragile state of health, consider the possible side affects. Vaccinate with intelligence, then detoxify!
Personal Information
First Name
Last Name
Address 1
Address 2
City
State
Zip Code
E-Mail
Home Phone
Office Phone
Cell Phone
Fax
Patient Information
Pet's Name
Breed (please be specific)
Date of Birth
Canine	Yes
Feline	Yes
Sex	Male Female
Spayed/Neutered (Date)	Yes Date
Weight
Diagnosis/Condition
Veterinarian's Name
Veterinarian Hospital
Veterinarian Phone
Veterinarian Fax
Please Indicate Which Option You Are Contacting Us For (Check One)
*Please Note - Phone Consultations Require a 24-Hour Notice Of Cancellation. A $25 Fee Will Be Applied If Not Provided.
	Nutritional Blood Test with Consult (Fee - $450) Blood To Be repeated in 3 months Supplements Not Included *Questionnaire & Blood Work from your Veterinarian are Required to complete the NBT CBC Superchem T4 LDH
	Nutritional Blood Test without Consult (Fee - $250) Blood To Be repeated in 3 months Supplements Not Included *Questionnaire & Blood Work from your Veterinarian are Required to complete the NBT CBC Superchem T4 LDH
	Follow-UP Nutritional Blood Test with Consult (Fee - $350) Blood To Be repeated as needed Supplements Not Included *Questionnaire & Blood Work from your Veterinarian are Required to complete the NBT CBC Superchem T4 LDH
	Follow-UP Nutritional Blood Test without Consult (Fee - $200) Blood To Be repeated as needed Supplements Not Included *Questionnaire & Blood Work from your Veterinarian are Required to complete the NBT CBC Superchem T4 LDH
	Phone Consultation with Dr. Bob (Fee - $300)
	Multi Animal Phone Consultation with Dr. Bob (Limited to two animals - Fee - $400)
	Bereavement/Emotional Healing with Susan (Fee - $125 per half hour)
	Diet Workup/Diet Consultation with Susan (Fee - $75 per half hour)
	Fax or Email Review/Reformulation (Fee - Starts at $50)
	Consultation With Your Animals Veterinarian (Fee - Starts at $50)
Questions About Your Pet
1. What is the specific condition, disease or diagnosis or your pet?

2. What specific tests were done to obtain this condition/diagnosis? (If healthy N/A)

3. What is your pet's current diet? (Include any table scraps. home cooked foods and treats)

4. What supplements (if any) is your pet receiving? (Vitamins, Minerals, Homeopathic, Enzymes, Antioxidants, Phytonutients etc..)

5. Is your pet currently taking any medications? If so, what is the specific name and dosage?

6. Is your pet currently receiving any type of therapy? (Acupuncture, Medical. Surgical. Chemotherapy, Radiation, Cortisone, etc..)

7. What is your pet's vaccination history? Be specific and include dates when possible. You may also fax this information into us.

8. In your opinion, what is your pet's emotional status and history?

Please add any additional comments or questions below.

How did you hear about us?