Thermal Imaging Request Form

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

Last Name

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Email

Phone

Preferred method of communication - email, text or phone call?

Patient Information

Pet's Name

Breed

Male / Female

Spayed / Neutered

Age / DOB

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