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.*

Animals Veterinarian*

Date of last Veterinarian appointment *

Patient (Animal's) Name*

Age*

Animals Date of Birth

Date

Gender*

FemaleMale

Neutered/Spayed*

YesNo

Species:*

HorseDogCatOther

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

Breed*

Color*

Weight*

(lbs)

Description/Markings on Animal:*

Temperament of animal (1=very calm and friendly, 10=aggressive; explain):

Any triggers/fears?

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):

I, _________________________, hereby give my consent for [Pet's Name]_________________ to receive chiropractic care from Madison Hoag, DC, Animal Chiropractic Practitioner. I understand that chiropractic care involves the assessment and adjustment of the musculoskeletal system of animals to restore proper function of the nervous system. The doctor is a licensed chiropractor, certified in animal chiropractic by the American Veterinary Chiropractic Association (AVCA), not a licensed veterinarian.

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 a great supportive therapy, chiropractic care is not intended to replace traditional veterinary medicine and cannot maintain primary responsibility for the animals care. I understand that while chiropractic adjustments are generally safe and well-tolerated, there are inherent risks associated with any manual therapy.

I agree to provide accurate and complete information about the animals 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 the animals 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 the animals condition and determine the appropriate course of chiropractic care. I agree to comply with any recommendations or instructions provided by the chiropractor regarding the animals care, including follow-up appointments and home care exercises.

I understand that I have the right to ask questions and seek clarification about the animals 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 my animal receiving chiropractic care from Madison Hoag, DC, animal chiropractor practitioner.

Pet Owner's Signature