Indian River Health Center New Patient Intake Form

Name of Owner*

First NameLast Name

Email*

example@example.com

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

How did you hear about us? If a friend referred you, please write their name so we can send them a referral credit!*

Do we have permission to post pictures of your pet on social media?*

YesNo

Name of Pet*

Pet's Age/Birthday if known*

Breed and Color*

Weight*

Is your pet Spayed or Neutered?*

Not spayed or neutered and don't plan toNot spayed or neutered but plan toYes, Spayed/Neutered

Vaccines: Please list vaccines given to your pet and dates given.*

Medical Conditions: Please list all current medical conditions and diagnoses as well as previous injuries, accidents and surgeries with dates:*

Medications and Supplements: Please list the medications and supplements that your pet is taking.*

Food: Please list the food your pet is eating.*

Veterinarian Name*

First NameLast Name

Veterinarian Clinic Name*

Veterinarian Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date your pet was last seen by the Veterinarian and why:*

Does your pet have a history of abuse and is your pet reactive?*

Reason for seeking chiropractic care:*

Has your pet ever been adjusted before?*

YesNo

What is your pet's current activity level? Do they compete?*

Is your pet used for breeding?*

YesNo

Please list anything else you would like us to know about your pet.*

If you have x-rays or medical files, please attach them here. This is not required but always helpful.

I, {nameOf} hereby authorize Indian River Health Center to examine and treat my animal(s). I certify my animal has had routine and current veterinary care and that I have been open and honest as to any and all other examinations, diagnoses, and treatments for my animal’s condition.

I understand that Dr. Ryan Hess, DC, CVSMT, CoAC is a Doctor of Chiropractic licensed in human care and has completed postgraduate education for certification in Veterinary Spinal Manipulative Therapy and a secondary certification from the College of Animal Chiropractic.

I understand that the employees of Indian River Health Center are NOT veterinarians and they do not intend to replace traditional vet care or take responsibility for my animal’s primary healthcare needs. I am seeking chiropractic for my animal(s) as a complementary therapy to be used concurrently with my current veterinary care. Chiropractic does NOT include: dispensing/injecting medication, performing surgery, recommending supplements, or providing any traditional veterinary care.

SCOPE: Indian River Health Center has explained their scope of practice and the procedures to be performed. They have explained risks and benefits of treatment to my satisfaction. I understand that there is no guarantee to the nature of my animal’s condition or the resulting outcomes of treatment. I understand Indian River Health Center's intent is to do no harm, but I also understand that negative reactions to treatment can occur (such as, but not limited to: fracture, dislocation, disc injury, strain/sprain, worsening of present condition, stroke, or neurologic impairment.) I will indemnify and hold harmless In Indian River Health Center and my referring veterinarian should any negative reactions occur.

LIABILITY: Indian River Health Center has made me aware that they carry their own malpractice and liability insurance. However, I understand that I am solely responsible for any harm caused by my animal to myself or any other animal, person, or property while under Indian River Health Center's care. This includes any financial obligation that may result due to my animal’s behavior.

FEES: Indian River Health Center has made me aware of their fee schedule. I agree to pay at the time of service for services rendered and for travel costs accrued. I do understand and consent that Indian River Health Center may save my payment information and can charge cancellation fees if I do not cancel within 24-hour notice of my appointment.

PET INSURANCE: I understand that Indian River Health Center is not a contracted provider with any insurance companies. My insurance policy is a relationship between myself and my insurer. Upon each service, I will be provided a detailed receipt that I may use for my own submission to my insurer. In submission, I understand there is no guarantee for reimbursement for services rendered and I do not hold Indian River Health Center responsible for providing any records or receipts to my insurance company as they have provided them to me, the owner, directly.

CANCELLATION POLICY: I understand that if I do not cancel an appointment within 24 hours of appointment time, Indian River Health Center will charge me a "late cancellation" fee of $25.00. If a late cancellation happens multiple times, my pet may be dismissed as a patient.

Sign here if you have read and agree to all of the consents above:*

Date of signing

Date

New Patient Intake Form

Medical History:

Consent for Treatment: