Integrative Medicine Intake Form

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Thank you for completing the form.
We will be in touch within 2 business days.

If you have blood test results or imaging data,
please send them via LINE or email.

All fields are optional — please fill in what you can. Press "Submit" when done.

01Basic InformationBasic Info

Pet's Name*

Owner's Name*

Furigana (if applicable)

Phone Number*

Species*

Cat Dog

Breed

Age

Sex

Male Female

Spayed / Neutered

Yes No

Weight (kg)

Preferred Contact Method*

LINE Email Phone

LINE ID / Email Address

02Purpose of VisitPurpose

Preferred Service*

Integrative

Integrative
Initial Consult

Integrated evaluation of constitution, lab data, nutrition & environment. Includes treatment planning.

Second Opinion

Second
Opinion

Opinion on current diagnosis or treatment. Concurrent care with primary vet welcome.

Personal

Personal
Consultation

Focused advice on diet, nutrition, lifestyle, and home care.

Appointment Type

In-person (Kadena, Okinawa) Online

03Main ConcernChief Complaint

Main concern / reason for visiting*

Since when

Primary Vet Clinic Name

Diagnosis from primary vet

Conditions that worsen or improve symptoms

Treatment history

04Lab & Diagnostic DataDiagnostic Data

Blood Test Results

Yes — will send Yes — older only None

Date of last test (approx.)

Other diagnostic data available

Diagnostic data and images cannot be submitted through this form. Please send them via LINE or email after submitting.
More data allows for deeper analysis from your very first visit.

05Medications & SupplementsMedications

Current medications

Supplements, herbal medicine & other

06Diet & LifestyleDiet & Lifestyle

Diet / food

Living environment

Activity level

Active Normal Low Very low

Possible stress factors

07Questions & Other NotesOther

What you most want to know / questions for the vet

Any other notes or requests

We will be in touch within 2 business days of receiving your form.

Integrative Medicine & Consultation Intake Form

Form Submitted Successfully