Animal Health Record
Owner Information
(tell us about you, human)
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
How did you hear about us?
*
Friend/Family
Social media
Google
Other
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Animal Information
Please fill out the following questions as complete as possible. If not applicable, please write NA.
Animals Name
*
Birthday
-
Month
-
Day
Year
Date
Type of Animal
*
Dog
Cat
Horse
Livestock
Rabbit
Other
Breed
Please list your animals colors/markings.
Gender
Male
Female
Is your animal spayed/nutered?
Yes
No
Is your animal up to date on their rabies vaccinations?
*
Yes
No
What is the reason for today's visit?
*
Please list all healthcare practitioners (veterinarian, massage therapist, chiropractor, rehab specialist, etc) your animal has seen and for what condition, if any. Please include any results and complications.
*
Please list all medications your animal is currently taking and what they are being used for.
*
Please list all vaccinations given to your animal.
*
Please list all supplements your animal is taking and what they are used for.
*
Please list any special diet your animal is on.
*
Please list any history of physical injury your animal has had.
*
Please list any history of surgeries.
*
Please describe your animals daily activities and energy levels.
*
Please list other information you think the doctor needs to know about your animals health.
*
Please list any behavior that is unique to your animal that the doctor should be aware of (nervous around fast motions or loud noises, bites if get near paws, etc) that could help her make a better connection with your animal.
*
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Authorization of Care
I recognize and understand that Dr. Brittany Freese, DC, CVSMT is a Minnesota State licensed Doctor of Chiropractic with Certification in Veterinary Spinal Manipulative Therapy from the Healing Oasis Wellness Center, and Animal Chiropractic Registration in the State of Minnesota. She is not a Veterinarian and therefore will not take responsibility for the primary health care of my animal. Chiropractic care is NOT intended to replace traditional Veterinary care, but is a complementary therapy that is to be used in conjunction with primary Veterinarian care. I hereby authorize Connect Animal Chiropractic, LLC, and in particular, Dr. Brittany Freese, DC, CVSMT, to treat my animal with animal chiropractic.
Signature
*
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Certification of Veterinarian
I certify that my animal has had routine, traditional veterinary care, and my current veterinarian is:
Veterinary Clinic Hospital Name
*
Name of Veterinarian doctor (if specific)
*
Veterinarian Phone Number
*
Please enter a valid phone number.
Signature
*
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Media Release
Connect Animal Chiropractic has my permission to use my animal’s picture and first name on social media sites operated by Connect Animal Chiropractic.
Signature
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Should be Empty: