New Client Intake Form

Name of Owner*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

How did you hear about us? If a friend referred you make sure to put their name so we can send them a referral credit! :)*

Do we have permission to post pictures of your pet on social media?*

YesNo

Name of Pet*

Breed, Color, and Weight*

Pet's Age/Birthday if known*

Spayed or Neutered?*

Not spayed or neutered and don't plan toNot spayed or neutered but do plan toSpayed/Neutered

Please list vaccines given and dates, supplements or medications that your pet is on, and what food your pet is currently on*

Primary Vet (please include name of veterinarian, name/address of clinic, date they were last seen and why) *

May we contact your primary vet for a referral? (please note that if you select "no" you will be responsible for collecting the referral from your vet. We cannot see your pet until we have a referral from your vet on file.)*

YES, please contact my vet for me.NO, I would like a PDF copy of the referral form and will have it signed myself

Does this pet have a history or abuse and/or is your pet reactive?*

Has your pet ever been adjusted before?*

YesNo

Reason for seeking care and when this problem started:*

Please list current medical conditions/diagnoses as well as previous injuries, accidents, and surgeries:*

What is your pet's current activity level? Do they compete? Used for breeding? *

Anything else you feel is important or that you'd like me to know?

If you have x-rays or medical files, you can attach them here. This is not required but always helpful if you do have them handy.

I, blanks*, hereby authorize Nose to Tail Chiropractic to examine and treat my animal(s). I certify my animal has had
routine and current veterinary care and that I have been open and honest as to any and all other examinations, diagnoses, and treatments for my animal’s condition.

I understand that Nose to Tail Chiropractic is comprised of Doctors of Chiropractic licensed in human care. Employees of Nose to Tail Chiropractic have completed postgraduate work in order to be eligible for certification by the American Veterinary Chiropractic Association / International Veterinary Chiropractic Association in order to practice animal chiropractic.

I understand that the employees of Nose to Tail 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 for my animal(s) as a complementary therapy to be used concurrently with my current veterinary care. Chiropractic does NOT include: dispensing/injecting medication, performing surgery, recommending supplements, or providing any traditional veterinary care.

SCOPE: Nose to Tail 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 Nose to Tail Chiropractic's intent is to do no harm, but I also understand that negative reactions to treatment can occur (such as, but not limited to: fracture, dislocation, disc injury, strain/sprain, worsening of present condition, stroke, or neurologic impairment.) I will indemnify and hold harmless In Stride Chiropractic and my referring veterinarian should any negative reactions occur.

LIABILITY: Nose to Tail 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 Nose to Tail Chiropractic's care. This includes any financial obligation that may result due to my animal’s behavior.

FEES: Nose to Tail 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 Nose to Tail Chiropractic may save my payment information and can charge cancellation fees if I do not cancel within 24-hour notice of my appointment.

PET INSURANCE: I understand that Nose to Tail 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 Nose to Tail Chiropractic responsible for providing any records or receipts to my insurance company as they have provided them to me, the owner, directly.

CANCELLATION POLICY: I understand that if I do not cancel an appointment within 24 hours of appointment time, Nose to Tail Chiropractic will charge me a "late cancellation" fee of $25.00. If a late cancellation happens multiple times, my pet may be dismissed as a patient.

Sign here if you have read and agree to all of the consents above:*