New Patient Form

We are so excited for you & your pet to begin your animal chiropractic journey! Take a few minutes to fill out this form as accurately as possible.

Please note that a veterinary referral form is required by law before we can perform chiropractic adjustments. You can send your veterinarian our Veterinary Referral Form link, found on our website.

*PEMF & Red Light appointments do not require veterinary referral*

Thank you for your time, if you have any questions feel free to reach out by phone or email. Visit our website www.companion-chiro.com for more information & online booking!

Owner Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Location

City & State

Veterinarian Information

Veterinarian’s Name

Veterinary Clinic Name

Pet’s Name

Sex

Date of Birth or Age

Species

Breed

Add any additional pets below:

List other animals also seeking care and why

Veterinarian Information

Veterinarian Clinic

What is the reason for the visit?

Mechanism of injury:

When did the problem begin?

Has it happened before?

Has your animal had any recent traumas, surgeries, or illnesses? If yes, list:

Include diagnosed health conditions such as arthritis, diabetes, Cushing, etc

Is your animal currently taking any medications or supplements? If yes, list:

Describe current diet (ex: raw, homemade, kibble brand):

Describe daily activity (ex: short walks, long runs, hikes):

Have they ever had any of the following previous care?

What specific goals do you hope to achieve?

What service(s) are you interested in?

How did you hear about us?

Add any additional information:

I,blanks* , owner of the animal listed above, being eighteen years of age or older, authorize the following:

Dr. Emily is a Doctor of Chiropractic, licensed to care for humans. She has completed many hours of specific Animal Chiropractic education at ACES.
Dr. Emily is NOT a veterinarian and is not responsible for the primary care of my animal.
Companion Chiropractic has my permission to share relevant records and information with my veterinarian as needed to care for my animal.
Chiropractic care does not replace traditional veterinary medicine and should be complementary to veterinary care.
There can be no guarantee of the nature of my animal’s condition or the outcome of any form of care.

I authorize Companion Chiropractic, in particular Dr. Emily Barber, Chiropractic Physician, to provide Animal Chiropractic care to my animal.

Signature

Can't wait to get started!

Dr. Emily Barber

Companion Chiropractic, LLC

765-490-7509

Companionchiro.llc@gmail.com

New Patient Form

Welcome to Companion Chiropractic!