DR. JACK LONG, VMD, CVA (CERTIFIED VETERINARY ACUPUNCTURIST)

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1 DR. JACK LONG, VMD, CVA (CERTIFIED VETERINARY ACUPUNCTURIST) INFORMATION ABOUT WHOLISTIC SERVICES WHOLISTIC CONSULTATIONS A wholistic consultation involves an analysis of your pet s health including review of previous history, records, lab tests, X-rays, etc., and a physical examination. Please complete the questionnaire and return it to our office via , fax, or mail. After we have received your questionnaire, we will call you to schedule your appointment. Please arrange for all available medical records, X-rays, and lab test results to be sent to our office or bring them to your appointment. You may need to pick up or arrange to have these records sent from your regular veterinarian. Dr. Long will be able to assess your pet's situation more completely and more quickly if he has all the information. He will discuss treatment options with you including conventional and wholistic treatments. Dr. Long's goal will be to develop an individualized customized treatment plan for your pet, which may include nutritional therapies (special diet, supplements such as vitamins, glandulars, enzymes), herbal medications, homeopathic medications, and chiropractic, acupuncture, and massage treatments. Please bring all supplements you are giving to your pet to the consultation. Initial consultations and follow-up consultations involve these processes: 1. Information gathering/assessment 2. Analysis 3. Prescribing 4. Counseling and Treatment

2 WHOLISTIC TREATMENT A wholistic treatment involves the administration of a specially selected combination of therapies that may include acupuncture needles and/or injections of homeopathic medicines or vitamins. The goal of each treatment is to support the physical and emotional well being of your pet. Treatments will help to stimulate your pet s healing abilities and promote balance of his/her physical and emotional energies. WHAT CAN BE TREATED? Wholistic therapies can be used to treat arthritis, allergies, autoimmune diseases, respiratory conditions, gastrointestinal disease, neurologic conditions, kidney disease, liver disease, cancers, urinary tract problems and many other diseases and injuries. HOW YOU CAN HELP - YOUR RESPONSIBILITY As medications or treatments are given, changes will usually begin to occur within 7-14 days. It is important that you keep a record of your observations. The changes may be physical or behavioral, such as changes in energy level, appetite, stool characteristics, urination, etc. Start making your observations on the day that the treatment or medication is given. This information is used to determine whether the medication is working. In general, acute diseases are cured in days to weeks. In chronic diseases, cure can take months to years. Fee for the initial consultation is $130. The consultation may take 45 to 60 minutes including the doctor s time previewing the records and questionnaire. Additional fees are charged for treatments, supplements, and medications. Fees for treatments are based on the special needs of your pet. With each visit a unique treatment plan will be designed to ensure the most comprehensive and appropriate health care. Treatment will be administered by selecting from the following services: Holistic Consultations - Initial min. $130 Follow-up 10-45min. $20 to $90 Acupuncture - needles only $90 - with electrostimulation $110

3 Homotoxicology Treatments - $135 Full 5 inj. treatment $90 Brief 2-3 inj. treatment Herbal & Homeopathic Preparations $30 to $60 Bach Flower Remedies Assessment/Preparations $10 to $50 PAYMENT POLICY CareCredit. Payment is expected at the time of service. We accept cash, checks, Visa, Mastercard, & CANCELLATION POLICY or reschedule. We ask that you contact us at least 24 hours prior to your appointment if you need to cancel

4 WHOLISTIC CONSULTATION QUESTIONNAIRE Owner Name Pet Name Address Phone Number(s) Age Sex Breed WELCOME! Thank you for inquiring about our wholistic consultation service at the Animal Hospital of Cloverdale. We need as much information as you can provide us about your pet: i.e., copy of veterinary medical records including x-rays, lab test results if possible, and the enclosed questionnaire filled out as completely as possible. To be able to evaluate your pet for homeopathic treatment, it is important to have as much information as possible about the physical, behavioral, and emotional symptoms of your pet. Specific details and characteristics are very important (e.g. questions 4,5,6). 1. In your own words describe the illness/condition. When it started, how it started? What is happening? How you feel about it & how it s affecting your pet: 2. What is your pet s diet? Include specific names of diets, supplements, table foods: 3a. Medications your pet is taking: drugs, heartworm, flea products, shampoos/dips, etc. Also any past medications used with dates if possible: 3b. Has your pet been vaccinated? If so, what vaccines and when where they given?

5 4a. What is your pet s temperament? (e.g., irritable, jealous, aggressive, calm, excitable) 4b. What makes your pet happy? 4c. What are its fears? (e.g., loud noises, new people, thunder, crowds, children, men, etc.) 5. What are your pet s primary (most noticeable or most severe) symptoms? Please list both physical and emotional. Are there any additional symptoms? Please check & comment on any symptoms that apply: eye discharge difficulty seeing nasal discharge mouth problems difficulty chewing difficulty swallowing ear problems hearing loss ear discharge, itch, redness coughing sneezing wheezing vomiting diarrhea straining (urine or stool) belching lameness pain unusual symptoms flatulence stomach noises weakness clumsiness stiffness COMMENTS: 6. Please observe these characteristics of your pet. It may be helpful to keep a journal for a few days/weeks. Please try to comment on each characteristic: Temperature Preference- What location in your house does your pet prefer? Does he/she prefer indoors or outdoors? What type of floor surface does he/she choose to rest or sleep on? Does he/she lie near a heat source/window/door/draft? Water Intake How much water does your animal drink compared to other animals?

6 What sources does he/she drink from? Does he/she prefer cold or warm drinks?---please do a test by putting down different temperatures of water or other liquids. Bowel Movements Is the stool soft, hard, mucousy, bloody? Is there variability in color or texture? Is there diarrhea or constipation? Please describe Urination Does your pet urinate more or less than what is normal? Does he/she have urine accidents in the house? Does he/she wet its bed? Does he/she strain to urinate? Is there any blood in the urine? Does he/she have urgency to urinate? Relationship with other pets/people Factors which influence the symptoms: Are they more frequent or obvious at certain time of day/night? before/after meals? with rest or movement? when your pet is indoor/outdoors? We require at least 24 hours advance notice for cancellations. Thank You. WHOLISTIC THERAPY RELEASE I consent to the use of wholistic therapies for my animal. I understand that I may refuse or discontinue these therapies at any time. I acknowledge that the use of wholistic or complimentary therapies may not be considered standard practice although they may have a long history of practical use and have been used effectively for animals by veterinary practitioners. Signature Date

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