Admissions Form

Full Name:*

First NameLast Name

Secondary owner/ Point of contact

First NameLast Name

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:*

E-mail:*

example@example.com

Pet's name:*

Species:*

Breed:*

Birthdate/Age:*

Color:

Sex:*

FemaleMaleSpayed femaleNeutered male

Primary veterinarian or clinic (we will send all after visit summaries/medical notes to the clinic listed):*

It is very important we have all medical notes, radiographs and records for your pet so your doctor can review this information before your appointment. PLEASE LIST ALL clinics or hospitals (including specialty services) your pet has been seen at for this issue:*

Reason for today's visit (i.e. which limbs are affected, when did injury, etc occur if known):*

* If your dog had surgery, please note the type of surgery, date, and facility where surgery was performed

Has your pet had any imaging (x-rays, MRI, CT, etc) for this issue?*

YesNo

If Yes, when and where?

How did you hear about us?*

Other

Does your pet have a social media account we can follow? (Follow us at Twin Cities Animal Rehab + Sports Medicine for clinic updates on Instagram and Facebook!)

I am OK with my pet's image being shared on social media*

YesNo

Treatment Authorization

I am the owner/agent of the described animal above and have the authority to execute this consent. I hereby authorize the veterinarian and staff of Twin Cities Animal Rehabilitation + Sports Medicine Clinic to examine and render treatment. I authorize the use of appropriate medical procedures, including sedation and other medications. I realize results cannot be guaranteed. I understand if I am more than 10 minutes late for my appointment, I may be required to reschedule.

I understand once my pet has entered a treatment program, an exam must take place every 6 months to remain a current patient. I understand a recheck is required before starting therapies following a surgical procedure, so that comfort and function can be reassessed to ensure therapies and exercises are appropriate for the patient. Similarly if recommended therapies are scheduled more than one month following an exam, an updated recheck exam may be required. I agree if the staff feels they are unable to safely examine my pet, I will be charged for the exam/doctor’s time and asked to reschedule a follow-up appointment after precautions have been made. I understand all medication refill request must allow 48 business hours for processing.

Payment Policy

I understand that cash or credit/debit cards are accepted. If authorization is declined for any reason on a credit or debit card, another method of payment is required. Full payment is required at the time services are performed. A verbal or written estimate will be provided. Pets must be collected by the end of their appointment or a late fee of $30 may be assessed.

Cancellation Policy

If I need to cancel my consultation, I understand I am required to give 24 business hours cancellation notice to retain my deposit. If I schedule future appointments and/or therapies, I understand I am required to the best of my ability to give 24 business hours cancellation notice otherwise I may be charged the full amount of the scheduled appointment.

TC Rehab's appointment software sends automatic appointment reminders to the email address I have provided, however I understand technology is not infallible and I accept the responsibility of knowing and accurately recording when I have scheduled my appointments.

______________________________________________________________

If my pet is prescribed hydrotherapy:

Hydrotherapy takes place in an underwater treadmill which is supplied by a 300-gallon tank of lightly treated, recycled, and filtered water that is changed on a regularly scheduled basis. When accidents occur in the hydrotherapy tank between these scheduled changes, the tank must be immediately dismantled and sanitized and the 300-gallon tank drained and refilled--this process takes over an hour and is very disruptive to our therapy schedule.

Owners bringing their pets in for hydrotherapy are required to do the following:

> Avoid feeding meals within 2 hours of pet's therapy session.
> Alert staff beforehand if your pet is incontinent or experiences accidents at home.
> Make every effort to have your pet fully defecate/urinate before their hydrotherapy session.
> Alert staff if your pet has not evacuated so that they may express/evacuate if necessary.
> Alert staff if your pet is or has been experiencing soft stools in the last 48 hours.
> Alert staff if your pet has any skin lesions or open wounds.
> Failure to make every effort to prevent an accident in the hydrotherapy tank by adhering to the above requirements may be subject to a $40 dumping and cleaning fee.

Thank you for adhering to our efforts to conserve our resources and keep our patients' therapies on time.

______________________________________________________________

I have carefully read the treatment authorization and the payment policy. By signing below, I agree to all conditions.

Signature:*

Today's date:*

Date