Thermal Imaging Request | Balanced Paws Rehab

Thermal Imaging Appointment Reuqest

This form is to request thermal imaging with interpretation ONLY. If you are interested in a more comprehensive examination and discussion, please use our New Consult Request Form.

Client Information

First Name

Co-Owner Name

Last Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Phone Number

Preferred Method of Contact (email, text, phone call)

Patient Information

Pet's Name

Male/Female

Age/DOB

Breed

Spayed/Neutered

Approximate Weight (lbs)

Do you have concerns about your pet? If so, please describe.

Does your pet have any current or past illnesses or injuries? If so, please describe.

Who is your primary veterinarian/ clinic and have you seen any other veterinarians for this issue?

What current medications and supplements is your pet receiving?

Does your pet have known food allergies or sensitivities?

What days work best for you?

Tuesday

Wednesday

Thursday

Friday

What time of day works best for you?

9:00am - 11:00am

11:00am - 2:00pm

2:00pm - 4:30pm

How did you hear about us?

Do you have pet insurance? If so, which one?

May we take photos of your pet and possibly use them for social media posts / marketing?

Yes

No, thank you

Thanks for submitting!