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:*

yesI spoke with an RMVR staff member and they discussed everything by phoneI still have additional questions (ask here)Other

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

Correct- please continue filling out the form. We look forward to meeting you.If you are trying to reach Dr. Jeff, please stop filling out this form and contact Planned Pethood.

I am filling out this form because*

I would like to schedule an appointmentI already have an appt scheduledOther (please enter more info in one of the free form sections farther down on the page)

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?*

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

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

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.*

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*

stairsother animals to play withslick floorsfree access to outside (dog/cat door)

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?*

1. Cancellation/No Show Policy

In order to meet the needs of our clients and to honor both your time and ours, any cancellation or appointment changes made less than 48 hours in advance will result in a scheduling fee. The amount of the fee will be equal to 100% of the reserved services.

2. Rescheduling after a last minute cancellation or no show

To book your next appointment, we will ask for a scheduling fee hold your spot for your next scheduled appointment. This scheduling fee will be equal to the cost of your upcoming visit and will be applied to that appointment. The scheduling fee is fully refundable with 48 hours notice. It is not refundable if you cancel with less than 48 hours notice or do not show up for your visit.

3. Scheduled Appointments

We do not have any kennels to safely keep patients beyond your scheduled appointment time. If you elect to drop off for your visit, is very important that you return at least 10 minutes before the scheduled end time of your appointment. If you are late to pickup, we may ask you not to leave the parking area or lobby for future visits. A fee of $5/minute may also be applied to discourage repeat offences.

Your signature below will indicate that you have read, understand, and consent to the cancellation and appointment policies above.

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Patient Intake Form

Scheduling Policy for Appointments