Animal Chiropractic Intake Form

Owner's Name

First NameLast Name

Today's Date

Date

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

Email

example@example.com

How did you hear about our Animal Chiropractic services?

Patient (Animal's) Name

Age

Gender

Neutered/Spayed

Species:

Upload a picture of your animal for our file if you have one please:

Breed

Color

Weight

(kg)

Temperament of animal (1=very calm and friendly, 10=aggressive; explain):

Any triggers/fears?

Trauma or Surgery:

Reason for seeking Chiropractic Care?

Health Current/Past Concerns:

Any recent changes in behavior? (If so, explain)

Condition/Illnesses (List any doctors seen for this condition, date last seen, diagnosis):

Description of Diet (also list known allergies):

Medications/Supplements:

Use/job of animal:

Previous Chiropractic Care (name of Doctor and dates):

I, hereby give my consent for my animal to receive chiropractic care from Dr Mark Illguth, Animal Chiropractor. I understand that chiropractic care involves the assessment and adjustment of the musculoskeletal system of animals to restore proper function and mobility.

I understand that while chiropractic adjustments are generally safe and well-tolerated, there are inherent risks associated with any manual therapy, including the risk of injury or exacerbation of pre-existing conditions.

I acknowledge that I have been provided with information about the benefits, risks, and alternatives to chiropractic care for animals, and I have had the opportunity to discuss any concerns or questions with the chiropractor.

Pet Owner's Signature