Their Best Life Animal Chiropractic Intake Form

  • New Patient Intake

  • Format: (000) 000-0000.
  • For Massachusetts residents, a Veterinarian acknowledgement is required prior to animal chiropractic care. This is basically just one signature on one page stating that they know you are being evaluated and possibly treated. Please check which box applies to you & this Vet. acknowledgment*

  • Animal Information

  • Sex of animal

  • Health History

  • Spayed/Neutered?
  • Has your animal ever bit another animal or human?*
  • Is your animal aggressive / fearful of other animals? (this helps with scheduling - in office appts)*
  • Has your animal ever had a reaction to vaccinations?
  • Have YOU, Yourself, the owner, ever been to a chiropractor? (helps with first visit education)

  • Current Health Status / Condition(s)

  • Check the symptoms/ conditions that your animal has or has had in the past
  • What preventatives / Rx / Supplements do you currently use?:
  • Check all that apply regarding frequency / occurrence of symptom(s)
  • What type of care have you tried for the main condition/symptom(s)?*

  • Owner Consents

  • Informed Consent about animal chiropractic:

    I, owner of the animal described above, understand and authorize the following: 

    1. Dr. Meaghan Cavallaro is not a veterinarian and cannot take responsibility for the primary care of my animal. Chiropractic care is not intended to replace traditional veterinary care, but is considered a complimentary adjunct/therapy to be used concurrently with a veterinarian’s care and recommendations. 

    2. Dr. Meaghan Cavallaro is a NBCE Board Certified Chiropractor that has completed advanced training in the field of animal chiropractic. She is animal chiropractic Certified through Health Pioneers Institute, an American Veterinary Chiropractic Association Approved Post Graduate Program.

    3. Dr. Meaghan has explained the scope of care and described the procedures that will be performed on my animal and the risks involved, or will do so on our first encounter. I understand those procedures and have had an opportunity to ask questions about them, or will be able to do so before we start treatment.

    4. Dr. Meaghan has explained and I understand that there is  no guarantee as to the outcome of any treatment (or complete resolution of symptoms). 

    I hereby authorize Their Best Life Animal Chiropractic, Dr. Meaghan Cavallaro, to treat my animal with animal chiropractic and as well as complimentary modalities including myofascial techniques and deep tissue laser therapy.

    Consent : Photo/Video Release:

    I understand that my animal may be photographed and/or videoed for clinical, case study,  and/or marketing use, and give my permission to have said images used on Their Best Life's website and/or social media accounts. I understand that only my pet’s firstname and image may be used for this purpose, and personal information including my (owner’s name) will be kept private. Said media is /will be the property of Dr. Meaghan Cavallaro, but if at any time I would like images of my pet removed from online platforms, I can submit a request in writing to Their Best Life Animal Chiropractic and it will be taken down within 7 days of the date the request was received.

    Veterinarian consent(s):

    If I live in the state of MA I will obtain a signature on an acknowlegement / referral form from my vet. prior to starting care. 

    Regardless of which state I live in, I consent to allow Dr. Meaghan to discuss my pet/animal's care with their veterinarian as medically necessary, or as requested by our vet. 

     

  • Finacial Info:

    Their Best Life does not accept insurance, all payments are due at the time of service. A fee schedule can be found through the website.

    If you would like a copy of an invoice, you may request one via email & it will be provided.

    Square, Inc. will be used for billing purposes and it is required to store a credit card on file after the first visit (you will see an option to do this on your first invoice). 

    Storage of Credit Card Information:

    By signing below, you authorize Their Best Life Animal Chiropractic, Dr. Meaghan Cavallaro, to store your credit card information for services rendered. Storage of this information is secure and confidential through Square, Inc. You can terminate the storage of your credit card by sending an email to TeamTheirBestLife@gmail.com. It is up to you to provide a new credit card after the expiration of the current card.

    Missed Appt Fees:

    It is office policy to give 24 hours notice if you can no longer make an appt. Please do so by emailing the office or sending a text message. There is a $50 fee for no-shows for in-office appointments, and for mobile appts, the fee is 50% of total service charges. 

    By signing below you also acknowledge that you are aware of the missed appt. policy. 

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