Animal Chiropractic Intake Form

Animal Chiropractic Intake Form

Healing Meadows Animal Chiropractic
Healing Meadows Animal Chiropractic uses this information for business purposes only. As far as this website and form, per Jotform's Website: "We do not sell personal information gathered from form responses. We won’t use any contact details collected in our customers’ forms to contact form responders."
Client's Information

(Owner of the animal to be treated)
Client Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Animal/Patient's Information
Animal's Name*
Date of Birth*

MonthDayYear
Date
Gender*
Animal's Species*
Animal's Breed*
Animal's Color*
Primary Vet Clinic*
Animal's Medical History
Purpose of visit: pain/wellness/performance and goals for care*
When did they start experiencing this problem? (If wellness select today's date)*

MonthDayYear
Date
Other Health Conditions

RashesDiabetes MellitusBone problemsSpasms/CrampsSprainsArthritisSeizuresSpinal Cord IssuesNeck painBack painHip painLeg painInfectious diseasesVision problemHeart issuesKidney disorderConstipationIncontinenceOther
Is your animal currently taking any medications or supplements? If yes, please list them below:
Did your animal undergo any surgery in the past? If yes, please indicate the name or location of the surgery:*
Authorization and Consent
- I recognize and understand that Dr. Jessica Donaldson 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 pet. 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 understand that Healing Meadows Animal Chiropractic operates in full compliance with all Minnesota laws and regulations. Therefore, it is required that a veterinary referral/signature of release for chiropractic services be completed prior to services rendered.
- I confirm that all information given in this form is true, complete, and accurate.
- I release Healing Meadows Animal Chiropractic and Dr. Jessica Donaldson, as well as the facility in which care is being provided of any responsibility in case of accident, illness, or injury to myself or my animal.
- I acknowledge that no assurance was offered about the outcome of care.
Financial Policy
Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the day that could have been filled by another patient. As such, we require 24 hour notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged a cancellation fee. Cancellation fees are the full service fee.
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Signature of the Client

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Animal Chiropractic Intake Form

Client's Information

Animal/Patient's Information

Animal's Medical History

Authorization and Consent

Financial Policy