Consultation Form for New Patients

Want to set up an appointment with Dr. Basko? It’s easy! Just follow these easy instructions to submit the form below:

Use our 3-part form below to submit all of your info
Be detailed!
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If your form is submitted correctly, you will be redirected to a confirmation page

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Name*
FirstLast
Email*
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Primary Phone Number*
Secondary Phone Number

Your Pet's Medical History
What is your reason for wanting a consultation? Please list out any current health issues your pet is having, if applicable.
If seeing another vet, what was their diagnosis of the current problem?
How long has your pet been ill?
Has your pet gone through stressful or traumatic situations prior to becoming sick (i.e. car accident, dog was a rehomed rescue, etc.)?
Which medication/supplements are you giving to your pet? How often? Dosage?
What is your pet's current diet? Previous diet? (Please be as detailed as possible).
Does your pet have any behaviorial issues, mild or moderate (i.e. aggression, anxiety, or shyness with new people or other animals)?
Any other previous major injuries or illnesses?
Have you seen a holistic veterinarian before?
- Yes
- No
If yes, what did they recommend?
Who is your primary veterinarian? May we contact him/her for your pet's prior vet records? (Please provide their phone number).
Do you practice some principles of holistic medicine in your own life (i.e. acupuncture, massage, etc.)?
Are you interested in learning more about home cooking food for your pet?
- Yes please!
- Not right now, thanks
- Possibly?
Who can we thank for referring you to Dr. Basko?
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Your Pet's Info