Romans Holistic Pet Service

Holistic Nutritional

Client Questionnaire
This program was created by Dr. Bob and Susan Goldstein

Please fill out the entire questionnaire and email or fax it back. Please remember to fax or email all diagnostics and test results from your veterinarian to Healing Center for Animals (fax back to 888-353-4817) Please call (at 203-227-4943) to confirm receipt of all required information.
Personal Information Date: Full Name: Address: City: State: Zip Code: Patient Information Animals Name: [ ] Feline [ ] Canine [ ] Horse Breed of Animal: Sex: Weight: Animals Veterinarian Information Veterinarians Name: Veterinary Hospital: Veterinarians Phone: Veterinarians Fax: Veterinarians email: [ ] Bird [ ] Other (please specify) : Age/DOB: Spay/Neutered: Yes [ ] No [ ] Date of Procedure: Home Phone: Office Phone: Cell Phone: Fax Phone: Email Address:

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Romans Holistic Pet Service

Holistic Nutritional

Client Questionnaire
This program was created by Dr. Bob and Susan Goldstein Questions 1. What is the specific condition, disease or diagnosis? 2. What specific tests were done to obtain this condition/diagnosis? 3. What is your animals current diet? (Include any table scraps. home cooked foods and treats) 4. What supplements or remedies is your animal receiving? (Vitamins, Minerals, Homeopathics, Herbs, Enzymes, Antioxidants, Phytonutrients etc.) 5. Is your animal currently taking any medications? If so, what is the specific name and dosage? 6. Is your animal currently receiving any type of therapy? (Acupuncture, Medical. Surgical. Chemotherapy, Radiation, Cortisone, etc...) 7. What is your animals vaccination history? Be specific and include dates when possible. 8. In your opinion, what is your animals emotional status and history? 9. Please add any additional comments or questions below. 10. How did you hear about us? (Please give person's name if a friend) 11. How would you like to receive information? [ ] Mail [ ] E-mail [ ] Fax [ ] Pickup at Holistic Pet Service ? 12. Which service are you interested in? Nutritional Blood Test (NBT) [ ] $450 with consult ] $350 with consult

Nutritional Pet Profile (NPP) [

Nutritional Wellness Program [ ] $100 Unsure of which service is right for your animal and would like a call to discuss [ ]

(Do not send credit card information through email) Credit Card # (MC/VISA/DISC/AMEX) _______________________________________________________________ Name On Card __________________________________________________ Exp. Date ______________________
WARNING: Speak with your Veterinarian before vaccinating your animal. If your animal suffers from a compromised immune system or is in a fragile state of health, consider the possible side effects. Vaccinate with Wisdom. We suggest titer testing. *A $25.00 fee will be charged to you if 24-hour notice is not given for cancellation of a Phone Consultation. Please Note: Food and Supplements sold separately Refund Policy on Services and Products: All custom formulations are non refundable. Nutraceutical Support Formulas and Liquid Remedies must be unopened with seal still intact and must be returned within 15 days from the ship date for a full refund.

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