Animal Chiropractic Intake Form

Owner's Name

First NameLast Name

Today's Date

Date

Phone Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

How did you hear about our Animal Chiropractic services? We are always sure to thank our referral sources.*

How did you hear about our Animal Chiropractic services?*

Patient (Animal's) Name*

Age*

Animals Date of Birth

Date

Gender*

FemaleMale

Neutered/Spayed*

YesNo

Species:*

Upload a picture of your animal for our file if you have one please:

Breed*

Color*

Weight*

(lbs)

Reason for seeking Chiropractic Care?

Trauma or Surgery:

Health Problems/Concerns:

Any recent changes in behavior? (If so, explain)

Condition/Illnesses (List doctors seen for this condition, date last seen, diagnosis):

Description of Diet (also list known allergies):

Medications/Supplements:

Use/job of animal:

Previous Chiropractic Care (name of Doctor and dates):

Animal's Primary Veterinarian *

First NameLast Name

Veterinarian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Veterinarian Phone*

Please enter a valid phone number.

Veterinarian Email*

example@example.com

Do you want to get your pet's referral signed by their veterinarian , or should we contact them?*

I will send them the form.You can contact them for me.My pet is being treated in Oklahoma.I don't know if my primary vet they will sign.

I, {ownersName40}, hereby give my consent for {patientanimals} to receive chiropractic care from Dr. Abby Esau, DC, Animal Chiropractor. I understand that chiropractic care involves the assessment and adjustment of the musculoskeletal system of animals to restore proper function and mobility.

I acknowledge that chiropractic care is a complementary therapy and is not a substitute for traditional veterinary medical care. I understand that while chiropractic adjustments are generally safe and well-tolerated, there are inherent risks associated with any manual therapy, including the risk of injury or exacerbation of pre-existing conditions.

I agree to provide accurate and complete information about {patientanimals} medical history, current health status, and any relevant veterinary treatments or procedures. I understand that this information will be used by the chiropractor to assess {patientanimals} condition and develop an appropriate treatment plan.

I understand that the chiropractor may need to perform a physical examination and/or diagnostic tests to evaluate {patientanimals} condition and determine the appropriate course of chiropractic care. I agree to comply with any recommendations or instructions provided by the chiropractor regarding {patientanimals} care, including follow-up appointments and home care exercises.

I understand that I have the right to ask questions and seek clarification about {patientanimals} chiropractic care at any time. I acknowledge that I have been provided with information about the benefits, risks, and alternatives to chiropractic care for animals, and I have had the opportunity to discuss any concerns or questions with the chiropractor.

By signing below, I acknowledge that I have read and understood the information provided in this consent form, and I voluntarily consent to {patientanimals} receiving chiropractic care from Dr. Abby Esau, DC, Animal Chiropractor.

Pet Owner's Signature