Animal Chiropractic Intake Form

Owner's Name

First NameLast Name

Today's Date

Date

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

How did you hear about our Animal Chiropractic services? We are always sure to thank our referral sources.

How did you hear about our Animal Chiropractic services?

Patient (Animal's) Name

Age

Animals Date of Birth

Date

Gender

Neutered/Spayed

Species:

Upload a picture of your animal for our file if you have one please:

Breed

Color

Weight

(lbs)

Description/Markings on Animal:

Temperament of animal (1=very calm and friendly, 10=aggressive; explain):

Any triggers/fears?

Reason for seeking Chiropractic Care?

Trauma or Surgery:

Health Problems/Concerns:

Any recent changes in behavior? (If so, explain)

Condition/Illnesses (List doctors seen for this condition, date last seen, diagnosis):

Description of Diet (also list known allergies):

Medications/Supplements:

Use/job of animal:

Previous Chiropractic Care (name of Doctor and dates):

I, [Pet Owner's Name], hereby give my consent for [Pet's Name] to receive chiropractic care from [Chiropractor's Name], DVM, Animal Chiropractor. I understand that chiropractic care involves the assessment and adjustment of the musculoskeletal system of animals to restore proper function and mobility.

I acknowledge that chiropractic care is a complementary therapy and is not a substitute for traditional veterinary medical care. I understand that while chiropractic adjustments are generally safe and well-tolerated, there are inherent risks associated with any manual therapy, including the risk of injury or exacerbation of pre-existing conditions.

I agree to provide accurate and complete information about [Pet's Name] medical history, current health status, and any relevant veterinary treatments or procedures. I understand that this information will be used by the chiropractor to assess [Pet's Name] condition and develop an appropriate treatment plan.

I understand that the chiropractor may need to perform a physical examination and/or diagnostic tests to evaluate [Pet's Name] condition and determine the appropriate course of chiropractic care. I agree to comply with any recommendations or instructions provided by the chiropractor regarding [Pet's Name] care, including follow-up appointments and home care exercises.

I understand that I have the right to ask questions and seek clarification about [Pet's Name] chiropractic care at any time. I acknowledge that I have been provided with information about the benefits, risks, and alternatives to chiropractic care for animals, and I have had the opportunity to discuss any concerns or questions with the chiropractor.

By signing below, I acknowledge that I have read and understood the information provided in this consent form, and I voluntarily consent to [Pet's Name] receiving chiropractic care from [Chiropractor's Name], DVM, Animal Chiropractor.

Pet Owner's Signature