At Safe Haven Veterinary Hospital, our mission is clear: Your Pet is Our Pet. Click here for a PDF version Pet Personality Quiz | Integrative Medicine Owner Information:Owner Name:(Required) First Last Today's Date:(Required) MM slash DD slash YYYY Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Primary contact phone number:(Required)Additional contact phone number:If added, is the above additional contact number for an additional owner/guardian? Yes No Email:(Required) Patient Information:Patient Name:(Required) First Last Species:(Required) Dog Cat Other Sex:(Required) Male Neutered Male Female Spayed Female Age/Date of Birth:(Required) Weight:(Required) Current Medications:(Required) Major Complications:(Required) Current Diet/Food:(Required) Patient Traits | FIRESelect all FIRE traits that apply to your pet:Normals lively communicative very friendly affectionate loves to be petted center of the party Abnormals insomnia separation anxiety restless excess heat rapid heart rate heart problems Patient Traits | WOODSelect all WOOD traits that apply to your pet:Normals decisive assertive confident strong impulsive athletic-stamina alpha animal Abnormals ligament problems liver problems red eyes anger easily ear problems nail problems footpad problems anal sac issues Patient Traits | EARTHSelect all EARTH traits that apply to your pet:Normals relaxed, laid back sociable round and large loyal serene and balanced cares for others (motherly) Abnormals diarrhea constipation loss of appetite vomits gum disease weak muscles overeats - obsese worries Patient Traits | WATERSelect all WATER traits that apply to your pet:Normals careful curious self contained likes to hide meditative slow and consistent Abnormals rear weakness fearful bone and back issues urinary problems disturbed growth deafness reproductive problems Patient Traits | METALSelect all METAL traits that apply to your pet:Normals loves order obeys the rules aloof symmetrical body disciplined attitude good haircoat Abnormals asthma dry skin sinus problems breathing disorder nose problems cough Other: PhoneThis field is for validation purposes and should be left unchanged. Δ Original Form Created By: Chi Institute of Chinese Medicine Tel: 800-891-1986 | www.tcvm.com