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.Format: (000) 000-0000.
Who may we thank for referring you to Barnyard Chiropractic?
Animal Name:*
Species:*
Breed*
Color/Markings*
Birthday*

MonthDayYear
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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
Clear communication keeps your animal safe and our time together efficient. These policies help us set shared expectations so we can focus fully on your animal’s care.
Appointments
Please have your animal caught, contained, and ready for examination at the scheduled time. They should be dry and lightly groomed so mud or debris does not interfere with the exam.

A person who knows the animal’s health history must be present. If that person is a minor, all registration forms must be completed and emailed in advance, including parent/guardian contact info.

Timing:
- Initial appointments: approximately 60 minutes
- Follow-up appointments: approximately 30 minutes
Please allow flexibility. Animals do not run on an exact clock, and sometimes road delays occur or urgent cases require priority. If I am running late for a mobile appointment, I will text you an updated ETA at least 15 minutes before your scheduled time. If your animal ever needs urgent accommodation, I will extend the same courtesy to you.
24-Hour Cancellation & No-Show Policy
Changes made within 24 hours of your scheduled appointment directly impact other animals who need care. If you cancel, reschedule, or do not show within 24 hours of your appointment, you will be charged the full appointment fee, including any applicable travel fees.

You will receive an email reminder three days before your appointment. Appointments rescheduled or canceled at least 24 hours in advance incur no fee.

If life happens, please notify me as soon as possible. Communication is always appreciated.
Coordination of Care with your Veterinarian
If you change veterinarians after the initial referral, please notify me right away. Your new veterinarian must complete an updated referral to maintain current and accurate health records for your animal.
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