Kopp Animal Chiropractic

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

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Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Primary Veterinary Name*

Veterinary Phone Number

Please enter a valid phone number.

Animal Patient Name*

Species*

DogCatHorseOther

Breed*

Age*

Weight*

Reason for visit*

Does your pet have any behavioral issues?

Was there a diagnosis given by a Veterinarian?*

NoYes

What was the diagnosis given by the Veterinarian?

When did the issue begin?*

How did the issue begin to the best of your knowledge?*

Is your pet eating/drinking normally?*

NoYes

Is your pet having normal urine and bowel movements?*

NoYes

Has your animal had this injury in the past?*

NoYes

Has your pet been diagnosed with Cancer or do you suspect possible Cancer?*

NoYes

Has your pet experienced unexplainable weight loss within the last 6 months?*

NoYes

Has your pet received Chiropractic or Laser Treatments in the past?*

NoYes

Has the problem gotten worse, better or stayed the same?*

WorseBetterStayed the same

Currently on medication or supplements (non-medication) ?*

NoYes

List Medication/s or Supplement/s(Non-Medication)*

History of surgery?*

NoYes

List Surgery and Year*

How long has your pet been a member of the family?*

How did your pet join your family?*

Any additional details or pertinent information about your pet?*

NoYes

Additional details or pertinent information:*

How many other animals are in the home?*

How did you hear about Kopp Animal Chiropractic?*

Google SearchReferralFacebookInstagram

Name of Referral*

Grant the rights to use photos or videos of your animals in Kopp Animal Chiropractic promotional ads?*

NoYes

I, {name} the undersigned, owner of {animalPatient}, and being eighteen years or older, do understand, substantiate, and authorize the following:

The purpose of chiropractic services is to promote natural health through the reduction of intervertebral joint restrictions (a lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact). The result of this can additionally cause alteration of nerve function and interference to the transmission of nerve impulses, resulting in a lessening of the animal’s innate ability to express its maximum health potential.

With broad variability across individual animal’s unique circumstances, it is difficult to predict the duration and frequency required for the recommended chiropractic procedures.

The chiropractic adjustment or other chiropractic-related clinical procedures are usually beneficial and seldom cause any problems.

Like most health care procedures, chiropractic treatments carries with it some risks. Unlike many such procedures, the serious risks associated with chiropractic care are extremely rare. Similar conditions across patients may respond differently to the same chiropractic care. In rare cases, underlying physical defects, deformities or pathologies, even certain health-challenged animals/breeds may render the patient susceptible to injury. Certain animals/breeds, such as chondrodystrophic breeds, are predisposed to respond unpredictably, or more commonly, less favorably to chiropractic care.

An owner of an animal, bringing the animal to the doctor of chiropractic, or requesting such services at their location, gives the doctor permission and authority to care for the animal in accordance with chiropractic tests, diagnosis, analysis and procedures. It is the responsibility of the patient to make known, or to learn through health care procedures whatever their animal is suffering from: latent pathological defects, illnesses or deformities which would otherwise not come to the attention of the doctor of chiropractic.

I hereby give my consent to the performance of diagnostic tests, procedures and chiropractic treatment or management of my animal’s condition(s).
Chiropractic care is proven to be one of the safest and most effective forms of healthcare available.

The provider/s treating and/or managing my pet/s chiropractic condition/s is/are a Doctor of Chiropractic, licensed in the care of humans. Additionally, he/she/they has received specialized training specific to Animal Chiropractic, and is therefore qualified to perform animal chiropractic services.

The provider/s treating and/or managing my pet/s chiropractic condition/s is/are NOT a veterinarian, and cannot take responsibility for the primary care of my animal.

Chiropractic care IS NOT intended to replace appropriate veterinary care, but intended to be used concurrently.

I have read and understand the scope of the animal chiropractic care my pet will receive. I understand and acknowledge and agree with the College of Animal Chiropractors description of Animal Chiropractic as follows: “Animal Chiropractic is the examination, diagnosis, and treatment of non-human animals through manipulation and adjustments of specific joints and cranial sutures”. Animal Chiropractic DOES NOT include: dispensing of medications, performing surgery, injecting medications, recommending supplements or replacing traditional veterinary care.

I realize there can be no guarantee as to the nature of my pet’s condition or the outcome of any procedure, and that the services are to only provide relief from those which are within the scope of animal chiropractic, as defined above.

I hereby authorize and give my consent to the performance of chiropractic tests, procedures, and chiropractic treatment and/or management of my pet’s chiropractic condition(s).

I certify that my animal has had regular veterinary care and is now concurrently being treated by: {primaryVeterinary}

I have read this authorization form, and understand it and give my consent.

Signature*