NEW CLIENT or PATIENT FORM

We are honored that you are willing to trust us with the care of your companion. As you are likely already aware, our practice is not the usual. We offer treatment in the form of homeopathic medicines and nutritional therapy (fresh food diets, vitamin and mineral supplements, and food concentrates). This type of treatment is emphasized because we feel it is the most effective way of dealing with a wide variety of health problems that our companions face. It is our opinion that homeopathic and nutritional therapy can be used to treat the same broad range of problems that are conventionally treated with drugs. It is also our experience that this is a very successful approach. 

However, not every problem can be successfully treated by us. Sometimes the disease is too advanced for our methods. Other times, we do not have the necessary knowledge or experience. Occasionally, our methods fail in spite of our best efforts. This is not stated to discourage you, but rather to honestly communicate our skills as well as our limitations. 

It is important to realize that regardless of the nature of the problem your companion suffers from, we are going to use the above-mentioned methods as first-line treatment, and conventional medicine as deemed appropriate. If it is our opinion that, for the well-being of your companion, you should receive care from another practitioner or by other methods, we will refer you for that care. 

If what has been presented above is acceptable to you and is what you wish for your pet, please fill out the form below. 

Thank you for considering Animal Wellness Center for your pet's healthcare.  Once this form is received, the office will be in touch with you with our next available appointment time.  

Declaration of Acceptance *
I have read the above explanation of the type of treatment offered by the Animal Wellness Center. I agree that this is what I want for my companion. I further state that I am not expecting any other treatment than what is described here.
By typing your name below, you acknowledge all of the above.
Date *
Date
Please type today's date
Your Name *
Your Name
Mailing/Billing Address *
Mailing/Billing Address
Home Phone Number *
Home Phone Number
Cellphone Number
Cellphone Number
Work Phone
Work Phone
Your current veterinarian records MUST be faxed or emailed prior to your appointment date; failure to do so may affect your appointment time or efficacy.
Veterinarian's Phone *
Veterinarian's Phone
Please list who referred you to Animal Wellness Center.
How familiar are you with homeopathy? *
Please, answer this question accurately as Homeopathic treatment is NOT the same has herbal or holistic treatment. By answering accurately, it helps us book an appropriate appointment time for you and your pet. If you don't know what Homeopathy is, please refer to ARTICLES; Homeopathic Tutorials (Home page) for details. Thank you!
Dog or Cat? *
Male or Female?
Spayed or Neutered? *
If you do not know your pet's exact age or date of birth, an approximate age is fine.
Please list your pet's vaccination history, including type of vaccination and date given.
Please list any medications that your pet is on, including dosage and frequency.
Please list your pet's current diet regimen.
Please list any supplements your pet is currently receiving.
Please tell us a bit about your pet's usual personality/temperament.
Please describe the reason for your visit to Animal Wellness Center.
Fee Schedule *
Consulting Fees: 4-15 minutes: $45.00; 16-30 minutes: $90.00; 31-45 minutes: $135.00; 46-60 minutes: $180.00. (a typical first appointment with Dr.Herman runs between 1-1.5 hours depending on the health condition of the pet) After Hour Emergency Phone Fee: $30.00 (plus time). Remedies and supplements are charged for separately and may have a shipping and handling fee depending on the size of package. These products are subject to Maine sales tax. ***There is a charge of $50.00 for appointments missed without a 24-hour notice*** ALL FEES ARE SUBJECT TO CHANGE WITHOUT NOTIFICATION
Payment *
Payment information will be taken at the time your appointment is scheduled.