Intake form and cancellation policy

Today's Date

Date

I confirm I have read the first FAQ on your website (RockyMountainVetRehab.com/faqs) and understand your fee structure and covid policies:

Other

I understand that you are not on TV and not associated with Animal Planet.

I am filling out this form because

How did you hear about us?

What is your name?

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Please list any additional phone numbers (i.e. home/cell) or contacts (i.e. partner name, number, email) here.

What is your profession?

What is your pet's name?

patient name

What species is your pet?

What is your pet's breed?

What color(s) is your pet?

When is your pet's birthday? (ok to estimate if it is unknown)

Date

What is your pet's sex?

How much does your pet weigh?

What is the main problem or concern that we will be seeing your pet for?

Who is your regular veterinarian? Please include multiple if you have seen specialists as this lets us know who to get records from.

Has your pet ever had imaging done? Xrays, radiographs, MRI, CT, ultrasound, etc.? If so, please note what was done and where.

If your pet has had any surgeries or has any ongoing medical conditions, please list them here. Include date of diagnosis or surgery date if known:

Please tell us more about what has been going on with your pet including approximate time when you noticed problems, what treatments you have tried and whether or not they have helped, and whether or not your pet seems to be getting better, worse, or staying the same since symptoms appeared:

What medications and supplements is your pet taking? Please include dose and how often each is given.

Please tell us about your pet's diet including type of food, how often and how much is fed. Include any treats or table scraps, if applicable.

Please list any allergies:

What is your pet's current level of activity?

What motivates your pet (ie. treats, toys, attention)?

On a scale of 1 to 10, where would you rate your pet's level of pain with 1 meaning none and 10 being debilitating.

Please follow this link to complete our baseline pain scoring sheet: https://form.jotform.com/261887900163058

What are your goals for your pet and for your appointment?

Has your pet ever harmed or shown signs of aggression toward any other person, dog, or cat? If yes, please explain.

Do you have Pet Insurance?

If yes, please list the company and policy number, if available.

Which set of characteristics most closely describes your pet?

Based on the 5 element theory

Home environment

We often take or receive pictures and videos during appointments to include in the patient's record. Do we have your permission to use this digital media online?

Would you like us to store a credit card on file for future payments? There is a 2% surcharge for credit card payments.

Text Communication Consent: Rocky Mountain Veterinary Rehabilitation may contact you via text message (SMS) for appointment reminders, pet care updates, medication or treatment information, and billing-related communication. Standard message and data rates may apply. You may opt out at any time by notifying the clinic. .

Other

1. Cancellation and No-Show Policy
To respect both your time and ours, any cancellations or appointment changes made less than 48 hours before your scheduled appointment will incur a scheduling fee equal to 100% of the reserved services. You may apply 50% of this fee toward your next scheduled visit. No-shows without prior communication will be billed at 100% of the cost of the missed visit.

A credit card can be kept on file for automatic billing of cancellations and checkout for future appointments. Please note, we do not make exceptions to this policy, including for illness. there is a 2% surcharge for all credit card payments.

2. Rescheduling After a Last-Minute Cancellation or No-Show
To reschedule after a last-minute cancellation or no-show, we require a scheduling fee to hold your next appointment. This fee will be equivalent to the cost of your upcoming visit and will be applied toward that appointment. If you provide 48 hours’ notice, the scheduling fee is fully refundable. However, if you cancel with less than 48 hours’ notice or do not show up, the fee is non-refundable.

3. Scheduled Appointments
As we do not have kennels to safely accommodate patients beyond their scheduled appointment time, we ask that if you choose to drop off your pet, you return at least 10 minutes before the end of the appointment. If you are late for pickup, you may be asked to remain on-site during future visits. Additionally, a late fee of $5 per minute may be applied to discourage repeated late pickups.

By signing below, you acknowledge that you have read, understand, and agree to the cancellation and appointment policies outlined above. You also consent to evaluation and treatment by Rocky Mountain Veterinary Rehabilitation.

Signature

Patient Intake Form

Scheduling Policy for Appointments