New Patient Registration: Large Animal

New Patient Registration: Large Animal

Please complete this registration form before the first appointment for your animal.
Owner Name*

First NameLast Name
Additional Owner Name

First NameLast Name
Owner Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Barn Address (if different from owner address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Email*
Appointment reminder emails are sent 3 days before to appointment.
Cell Phone*
Please enter a valid phone number.
Who may we thank for referring you to Barnyard Chiropractic?
Animal Name:*
Species:*
Breed*
Color/Markings*
Birthday*

MonthDayYear
Sex*

MaleFemale
If your animal has been altered (e.g., gelded, spayed), how old were they for the surgery?
How long have you know or cared for your animal?*
Please upload a photo of your animal.
Name of Primary Veterinarian and/or Veterinary Clinic*
Veterinarian Phone Number*
Please enter a valid phone number.
Why are interested in chiropractic care for your animal?*
List and describe any current health concerns or injuries as well as any history of injuries, illnesses, and/or conditions experienced by your animal (e.g., lameness, infections requiring antibiotics, skin allergies). *
Please list any current medications and when it is given. If none, write DNA : *
Because chiropractic adjustments can activate the innate immune system, animals will not be adjusted within 1 week before OR after vaccination to limit the risk of reactions. Please select the option from the dropdown menu that applies to your animal. *
If necessary, we will contact you to reschedule.
Date of Last Dental Float

MonthDayYear
Date
Date of Last Farrier Appointment

MonthDayYear
Date
Describe daily feeding schedule including amount of hay, supplements, and/or treats given:*
Select the option that best describes how your animal eat food:*
Select the option that best describes how well your animal drinks water:*
EMERGENCY CONTACT: Please provide the name and phone number for someone who we could call on YOUR behalf in the event of an emergency.*
Name
EMERGENCY CONTACT PHONE NUMBER*
Please enter a valid phone number.
If you have veterinary records for your animal (e.g., veterinary reports, laboratory reports), please upload the documents here. If you have an X-ray viewing link, please forward the link to drnatalia@barnyardchiropractic.com.

Cancelof
Submission and Electronic Signature Agreement: By signing and submitting this form electronically, you acknowledge that your typed name constitutes your legal signature, equivalent in all respects to a handwritten signature. By submitting this form, you confirm that all information is true, accurate, and complete to the best of your knowledge. If there are any changes to the information submitted in this form including if you change primary Veterinarian, you agree to update us as soon as your next appointment. If you prefer not to use an electronic signature, please print this form, sign it manually, and send me a text at 630-394-4228 letting me know you have a paper copy. Thank you!*
Name*
Date

MonthDayYear

Practice Policies
I believe clear communication is the foundation to every healthy relationship. My practice policies are intended to establish expectations, so we can focus on helping your animal heal and be well.
Appointments
To optimize our time together, please have your animal caught, contained, and ready for examination. Dogs should wear a soft or choke collar (no prongs). Cats should be contained where they cannot escape under/behind furniture.

A person who knows the health history of the animal must be present for the appointment. If that person is a minor, all registration forms must be completed and emailed in advance including the contact information for a parent or guardian.

Please plan on 60 minutes for initial and 30 minutes for follow-up appointments. Sometimes appointments take longer than expected or things happen on the road. If I am running late for a mobile appointment, I will text you my estimated arrival at least 15 minutes before our scheduled time. Sometimes an animal needs to be seen urgently due to injury or illness, and I need to shuffle my schedule. I will do my best to reschedule with your animal same day or within 24 hours. Thank you for understanding that the same accommodation will be made to you and your animal if ever needed.
24-Hour Cancellation & No-Show Policy
Appointment changes within 24 hours of our scheduled time impacts my ability to serve other animals. Rescheduling or cancelling within 24 hours of our appointment or no-showing will result in being charged the full cost of the appointment including any applicable travel fees. Credit card information is stored with Stripe, which complies with current data protection practices. Additional information is available upon request.

I understand life happens, so please notify me as soon as possible if you need to reschedule for any reason. Email appointment reminders are sent 3 days in advance. There will be no fee for appointments rescheduled/cancelled at least 24 hours in advance.
Coordination of Care with your Veterinarian
If you change veterinarians after the initial referral form has been completed, please notify me as soon as possible. The referral must be updated by your new veterinarian to maintain their health record and compliance with Illinois state laws.
Payment
Payment is expected at the time of service. I accept cash, check, and all major credit cards, which are processed using the QuickBooks app. If the person responsible for payment will not be present at the appointment, please make arrangements ahead of time.
Submission and Electronic Signature Agreement: By signing and submitting this form electronically, you acknowledge that your typed name constitutes your legal signature, equivalent in all respects to a handwritten signature. You confirm that you have read, understand, and agree to follow the Practice Policies outlined above. If you prefer not to use an electronic signature, please print this form, sign it manually, and send me a text me at 630-394-4228 letting me know you have a paper copy. Thank you!*
Name*
Date

MonthDayYear
Should be Empty:

New Patient Registration: Large Animal

Practice Policies

Appointments

24-Hour Cancellation & No-Show Policy

Coordination of Care with your Veterinarian

Payment