Chiro Consent Form

Veterinarians - please review your client and patient's info below before proceeding to approve their request on page 2.
New Client Form
Owner Name*

First NameLast Name
Animal Name
{animalName}'s age/gender/breed/color
Type of animal:

HorseDogOther
Show owner consent details:

NoYes
I am of lawful age, do understand, authorize, consent, and can substantiate the following:

1.         CREDENTIALS: In Stride Chiropractic is comprised of Doctors of Chiropractic licensed in human care. Employees / contractors of In Stride Chiropractic have completed postgraduate work in order to become certified by the American Veterinary Chiropractic Association / International Veterinary Chiropractic Association in order to safely and effectively practice on animals.

2.         SCOPE: The employees / contractors of In Stride Chiropractic are not veterinarians and they do not intend to replace traditional vet care or take responsibility for my animal’s primary healthcare needs. I am seeking chiropractic and/or rehabilitation for my animal(s) as a complementary means to be used concurrently with my current veterinary care. Texas Law states: “Animal Chiropractic and other forms of musculoskeletal manipulation are systems of therapeutic application of mechanical forces applied manually through the hands or any mechanical device to diagnose, treat and or alleviate impaired or altered function of related components of the musculoskeletal system of non-human animals. Chiropractic…[is] considered to be [an] alternate therap[y] in the practice of veterinary medicine.” 22 Tex Admin Code § 573.14. Our care does NOT include: dispensing/injecting medication, performing surgery, recommending supplements, or providing any traditional veterinary care.

3. SUPERVISION: Texas law states: “Alternate therapies, including ultrasound diagnosis and therapy, magnetic field therapy, holistic medicine, homeopathy, chiropractic treatment, acupuncture, and laser therapy, are performed only by a veterinarian or under the supervision of a veterinarian” Sec. 801. 151 It is therefore recommended, that in states where the practice act permits, a chiropractor working on animals perform all services with SUPERVISION from a licensed veterinarian providing concurrent care.

4.         RECORD SHARING: I hereby allow In Stride Chiropractic and my referring vet to share any and all records so they can better collaborate on my animal’s treatment. I allow In Stride Chiropractic to share records with any and all members of my animal care team (I.e: trainers, massage therapists, groomers, etc). I hereby also allow use of my pet’s health information for research purposes.

5.         INFORMED CONSENT: In Stride Chiropractic has explained their scope of practice and the procedures to be performed. They have explained risks and benefits of treatment to my satisfaction. I understand that there is no guarantee to the nature of my animal’s condition or the resulting outcomes of treatment. I understand In Stride Chiropractic’s intent is to do no harm, but I also understand that negative reactions to treatment can occur.

6.         LIABILITY: In Stride Chiropractic has made me aware that they carry their own malpractice and liability insurance. However, I understand that I am solely responsible for any harm caused by my animal to myself or any other animal, person, or property while under In Stride Chiropractic’s care. This includes any financial obligation that may result due to my animal’s behavior.

7.         FEES: In Stride Chiropractic has made me aware of their fee schedule. I agree to pay at the time of service for services rendered and for travel costs accrued. I do understand and consent that In Stride Chiropractic may save my payment information and can charge cancellation fees if I do not cancel within 24-hour notice of my appointment. I understand that they can deny future services if I have a credit on my account.

8.         PET INSURANCE: I understand that In Stride Chiropractic is not a contracted provider with any insurance companies. My insurance policy is a relationship between myself and my insurer. Upon each service, I will be provided a detailed receipt that I may use for my own submission to my insurer. In submission, I understand there is no guarantee for reimbursement for services rendered and I do not hold In Stride Chiropractic responsible for providing any records or receipts to my insurance company as they have provided them to me, the owner, directly.

9.         POLICIES: I agree to abide by the practice policies posted on In Stride Chiropractic’s website.
I, {ownerName}, hereby authorize In Stride Chiropractic to examine and treat my animal(s). I certify my animal has had routine and current veterinary care and that I have been / will be open and honest as to any and all other examinations, diagnoses, and treatments for my animal's condition.*

Clear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
How did you hear about us?
Do we have permission to post pictures / videos of you animal(s) on social media?

YesNo

Veterinarian Information
Veterinarian Name*
Vet Address
Vet Email*
example@example.com
Vet Phone*
Vet Fax
I, {veterinarianName}, in compliance with Rule 573.14, have performed the following:

1. Established a valid veterinarian/client/patient relationship.

2. Examined the animal(s) to determine that the above therapies are appropriate.

3. Obtained a signed acknowledgement by the patient's owner that the above therapies are considered under state law to be alternative and nonstandard.
I, {veterinarianName}, approve or deny this request for the animal(s) listed to receive care from In Stride Chiropractic:
Veterinarian Approval Signature

Clear
Vet Notes regarding {animalName} owned by {ownerName} that are pertinent to the care and / or treatment by In Stride Chiropractic:
Any relevant medical records regarding {animalName} owned by {ownerName}:

Cancelof
FOR CLIENTS: Once you submit this form, we will send it to your veterinarian for their approval and keep you posted on if they approve or deny your request for care with us. Once completed, we will then send you a link to get scheduled & started with the new patient history forms.
FOR VETS: Once you submit this form, it will send a notification to you for your records & to our mutual client.
Once you submit this form, it will send a DENIED pdf to our mutual client.
Should be Empty:

Veterinarians - please review your client and patient's info below before proceeding to approve their request on page 2.

New Client Form

Veterinarian Information

FOR CLIENTS: Once you submit this form, we will send it to your veterinarian for their approval and keep you posted on if they approve or deny your request for care with us. Once completed, we will then send you a link to get scheduled & started with the new patient history forms.

FOR VETS: Once you submit this form, it will send a notification to you for your records & to our mutual client.

Once you submit this form, it will send a DENIED pdf to our mutual client.