New Rehab Patient Packet Form

New Rehab Patient Packet Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Best day Monday through Friday for appointments*
How did you hear of us?*

OnlineReferral
Which website?*
Whom should we thank?*
I understand and agree to CHAH rehabilitation and pain management department’s cancellation policy of 24 hours’ notice. If I am unable to cancel my appointment without 24hours’ notice I agree to pay a cancellation or no-show appointment fee.

I ensure that my pet has been taken to go potty prior to their rehab appointment. I understand that if my pet defecates in the underwater treadmill that it closes the treadmill down for a deep cleaning and decontamination process. If my pet defecates in the underwater treadmill, I agree to pay a $125 decontamination fee.

My pet will be bathed and cleaned prior to their rehab appointment. If they need bathed prior to getting in the underwater treadmill, I understand there will be a $49 bath charge
Signature*

Clear
Date*

MonthDayYear
Date
I would like to keep my credit card on file at CHAH for easier checkout/patient pick up experience. By providing my credit card information and signing this form, I am authorizing CHAH to charge the following credit card for treatments and services provided
Name on the card*
Type of card*
Card number*
Expiration date*

MonthDayYear
Date
Security code*
Billing zip code*
Signature*

Clear
Date*

MonthDayYear
Date
Authorization For Treatment
The following agreement is made between Central Houston Animal Hospital, Rehabilitation and Pain Management department and the person represented below.

I hereby authorize rehabilitation and holistic pain management to be performed on my animal. I have been informed of possible complications and the anticipated prognosis. I acknowledge that rehabilitation therapies, massage and spinal manipulation are considered alternative therapies by the Texas Board of Veterinary Examiners and the Texas State Veterinary Medical Association.

These treatments will be performed by Kristina Adourian, LVT, CCRP under direct supervision of the veterinarians at Central Houston Animal Hospital, specifically Jessica Marziani, DVM, CVA, CVC, CCRT. I have discussed with Kristina Adourian and/or Dr. Marziani the treatment options available for my pet, both traditional/conventional therapies offered by my regular veterinarian and alternative therapies. After consultation, I understand the treatment and the risks involved in alternative therapies. Kristina and/or Dr. Marziani have encouraged me to discuss any concerns that I may have about risks before treatment and anytime throughout treatment.

While I accept that all procedures will be done to the best of Kristina Adourian and/or Dr. Marziani’s abilities, I understand that no guarantee or warranty has been or will be made regarding the results that may be achieved.

I, the undersigned owner or representative, of the pet identified below, consent to all future examinations and treatments of my pet by Kristina Adourian and Dr. Marziani using alternative therapy methods. My signature on this form indicates that: (a) any questions I have regarding alternative therapy have been answered to my satisfaction; and (b) my consent to any future treatments will only be provided after receiving information from Kristina Adourian and/or Dr. Marziani on conventional treatments available and their probable ability to cure the problem.
I give consent for all future alternative therapy treatment for the following pet*
Printed name of owner or representative of the above-named pet*
Signature of owner or representative of the above-named pet*

Clear
Date*

MonthDayYear
Date
Patient Information Form
Name of pet*
Name of owner*
Pet Age/Birthday*
Species*
Breed*
Color*
Weight*
Sex*

MaleFemale
Spayed/neutered?*

YesNo
Please have any medical records and radiographs pertaining to current problem/illness or previous lameness/musculoskeletal problems emailed to rehab@chahpets.com prior to your initial appointment.
Primary care veterinarian name and clinic*
Do you want CHAH rehab to follow up with your primary care veterinarian?*

YesNo
If yes, Veterinarian’s email address*
example@example.com
Does your pet have food allergies?*

YesNo
If yes, what?*
What is your primary reason for seeking rehabilitation and/or pain management therapy for your pet? Please explain details including length of time for this concern, how you believe it started and what you have tried to help your pet with this concern and if that helped or not.*
List any additional medical problems we need to be aware of:*
List any major surgeries your pet has had and approximately when they occurred:*
List any behavior problems we need to be aware of:*
List any medications and supplements you give your pet (brand, quantity and frequency):*
Describe your pet’s daily routine:*
Does your pet need to be able to do stairs? If so, how many and how often:*
Have you noticed any changes in the following for your pet?*

Water intakeVomitingAppetiteStool qualityUrinationMentationMobilitySleeping patternsAnxietyPerformanceCoughingSkin/hair coatTemperature preferenceMuscle conditionActivity levelDifficulty standingDifficulty sittingDifficulty laying downDifficulty with slick floorsDifficulty on stairs
Please explain any of the above changes, including onset, duration and treatments tried (please be as detailed as possible):*
On a scale of 1 to 10 with one being my pet is in no pain and ten being my pet is in excruciating pain, please rank where you feel your pet is today:*

1

2

3

4

5

6

7

8

9

10

1 is No pain, 10 is Excruciating pain
On a scale of 1 to 10 with one being my pet’s quality of life is fantastic and ten being my pet’s quality of life is no longer acceptable, please rank where you feel your pet is today:*

1

2

3

4

5

6

7

8

9

10

1 is Fantastic, 10 is No longer acceptable
On a scale of 1 to 10 with one being my pet’s quality of life is fantastic and ten being my pet’s quality of life is no longer acceptable, please rank where you feel your pet is today:*

1

2

3

4

5

6

7

8

9

10

1 is Fantastic, 10 is No longer acceptable
Please rank your pet’s lameness (if they are lame) on a scale of 1 to 5: *

Grade 1: Dog walks normallyGrade 2: Slightly lame when walkingGrade 3: Moderately lame when walkingGrade 4: Severely lame when walkingGrade 5: Reluctant to rise and will not walk more than a few steps
Please describe activities or times when your pet’s lameness is worse than other times:
What is your goal for rehab?
Should be Empty:

New Rehab Patient Packet Form

Authorization For Treatment

Patient Information Form