• Intake Questionnaire - Dog

  • Thank you for booking an appointment with The Veterinary Behavior Center!

    Our team is committed to helping you and your pet have a happier and healthier life together. Here you will find important information about working with us and a patient questionnaire. All information provided on these forms is strictly confidential.

    We will reach out to your primary care veterinarian directly for medical records.  If you have any notes from a trainer, feel free to email those to info@vetbehaviorcenter.com in advance of your appointment.  

    If you have scheduled an appointment for more than one pet in your household, please fill out a form for each pet.

    If you have any short videos that demonstrate the behavior problem, click here to request a Dropbox link to upload them.  Never incite or prolong an aggressive or stressful event just for the sake of a video - this could be a bad learning experience for your pet and may be a safety risk. 

    Please complete this paperwork at least 3 days before your appointment.

    Additional information about our Center, including your financial investment, can be found at www.vetbehaviorcenter.com or feel free to call or email. Please let us know if you have any questions in the time leading up to your appointment.

     We look forward to meeting you and your pet(s)!

     

     

    - The Veterinary Behavior Center team

  • Basic Information



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  • Statement of Mutual Understanding

  • STATEMENT OF MUTUAL UNDERSTANDING

     

    Thank you for seeking out the services of The Veterinary Behavior Center, LLC.  Living with behavioral disorders in pets can be very stressful, and we are honored that you have trusted us to help you and your family.

     


    Reasonable expectations are important when treating behavioral problems. While in some cases we are able to treat elements of a behavioral condition relatively rapidly, the majority of behavioral improvement occurs over time.  Behavior change is a process.  Allow us to lead you through this process and most pets can show improvements. Your participation in this process, and consistent follow through, is essential for success.  While improvements are common with many behavior problems, most behavior problems are not completely curable.  For instance, if your pet is growling, snarling, snapping or biting, while we may be able to decrease the frequency and intensity of these behaviors, it is likely that, even with treatment, this behavior will occur at some point to some degree in the future.  Our goal is to help you decrease the problem behavior to a level that at the very least you can comfortably live with and maximizes your pet's quality of life.  Because each pet is an individual, there can be no guarantee on the results of treatment.

     


    You could be held legally and financially responsible for any injuries that your pet causes.  And, you alone are responsible for avoiding situations that could result in injury.  By signing this form The Veterinary Behavior Center, LLC, Dr Ariel Fagen, or any other person employed by or affiliated with The Veterinary Behavior Center, LLC will not be held responsible for any injuries that may happen to you, other people, other animals or your pet during the course of treatment. 

     


    Furthermore, you agree to indemnify and hold The Veterinary Behavior Center, LLC, Dr Ariel Fagen, or any other person employed by or affiliated with The Veterinary Behavior Center, LLC harmless from and against any third-party claims, damages, liabilities, actions, judgments, suits, costs, disbursements and expenses of any kind of nature, including, without limitation, reasonable fees and disbursements of counsel, that may be imposed on, incurred by or asserted or awarded against The Veterinary Behavior Center, LLC, Dr Ariel Fagen, or any other person employed by or affiliated with The Veterinary Behavior Center, LLC in connection with the treatment of your pet.

     


    By signing below you acknowledge the above information.  You are the owner(s) of the animal(s) seeking treatment from The Veterinary Behavior Center, LLC.  You acknowledge the risks inherent in owning an animal and accept the liability associated with it.  You understand that all fees are to be paid at time of service and you accept full responsibility for fees incurred at The Veterinary Behavior Center, LLC during the diagnosis and treatment of your animal.

     



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  • Payment Policy

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    We accept all major credit cards.​

    We are happy to fill out forms for pet health insurance companies.  Please check for exclusions carefully, such as waiting periods and pre-existing or breed-specific conditions.  Not all insurance companies cover veterinary behavior treatment.  

    No refunds will be given for services rendered.

    We always try to be transparent with the financial investment involved with our services.  We never want people to feel blind-sided.  Please see our website for the most up-to-date numbers and do not hesitate to reach out if you have any questions.

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    All payment is due at time of service, no exceptions.  

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    Deposits & Pre-payments

     

    Many patients out there need our care and in order to protect our community of clients and patients, we have created a deposit and pre-payment policy so that open slots can be filled by patients who need them.  Additionally, up to 1.5 hours of employee preparation time occurs in advance of each appointment, so this helps cover those costs.  We value our employees and want their time to feel valued.  To protect these interests, the following policy is in place:

     
    Deposits:  A non-refundable deposit of $75 is required for all appointment types, with the exception of our Brush Up Appointments.  If an appointment is rescheduled or cancelled more than 72 hours prior to the appointment this deposit is transferred to the next appointment, no matter the appointment type.  Just give us that 72 hours notice (and a chance to fill that slot!) and you can do this as you need.  If an appointment is rescheduled or cancelled less than 72 hours prior to the appointment, or a client does not show up for the appointment, this deposit is taken as a cancellation fee.

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    Pre-payment:  Life happens, we know that, so we want to give you a little wiggle room.  The first time a client reschedules or cancels less than 72 hours prior to the appointment, or does not show up for a scheduled appointment, we will keep the deposit as a cancellation fee.  If this happens more than once we will ask you for the full appointment fee as pre-payment.  As with the deposit, this is non-refundable and cannot be transferred to other appointments if a reschedule occurs within 72 hours of the start time of your appointment. 

    Treatment packages: The purchase of treatment packages are non-refundable and non-transferrable, even if there are remaining unused treatment appointments. 

    Please sign here to indicate you understand and accept this payment policy.

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  • General Pet & Lifestyle Questions




  • Medical Background

  • General Behavioral Background

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  • Please describe the top 3 reason(s) that you are scheduling the Triage Appointment.  If only one reason, feel free to skip sections entitled Behavior Problem #2 and Behavior Problem #3 and proceed directly to General Behavior Information below.  

  • Behavior Problem #1


  • Behavior Problem #2


  • Behavior Problem #3


  • General Behavior Information


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  • Aggression Screen


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  • Additional Information

  • If you have any photos that demonstrate the problem behavior(s) that you would like to share, feel free to upload them in TeleVet You may also email them to info@vetbehaviorcenter.com.

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  • Informed Consent on Use of Telehealth Services

  • The Veterinary Behavior Center, LLC utilizes telehealth services as a platform to provide treatment to our patients at a distance. The veterinarian assumes responsibility for making medical judgements and providing recommendations accordingly. Through our telehealth services we are able to perform and assess video/live stream based body language and behavioral assessment, comprehensive intake interview, review of patient medical records and previous diagnostics. We are able to make diagnoses, recommend diagnostics, determine prognosis, prescribe, engage in client education, assist with administrative support and develop and administer full treatment plans. The client understands while there are inherent limitations to telehealth services, including inability to perform physical exams, in person behavioral assessment and undertake certain diagnostics, the veterinarian is making medical judgments to the best of their ability with the provided information and will inform the client on any limitations and additional diagnostics or in-person evaluation needed for best quality of care. The client accepts such recommendations and agrees to follow them to the same extent they would any recommendations received via in person consultation. The veterinarian determines the appropriateness of telehealth services based on individual case and telehealth services may be declined at any time by the veterinarian if it is determined to not be in the best interest of the patient at the veterinarian's sole discretion. The client may decline telehealth services at any time if they choose. To perform telehealth services, clients and patients must be located in the State of Colorado and must be seen in-person at the time of establishing an initial veterinarian-client-patient relationship and at minimum once yearly. By signing this form you consent that you are located in Colorado and understand and agree to how telehealth is used in our practice.

     

    **COVID-19 Update:  The Governor of Colorado has currently waived the requirement to meet in person once yearly to treat a patient to promote telehealth and social distancing during this pandemic.  This is expected to end at the end of the crisis.  All patients that have not been seen in person within the past year may be required to do an in person evaluation in order to continue treatment. 

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  • Educational Use Release

  • The Veterinary Behavior Center, LLC seeks permission to use any recordings, photos and videos for the purposes of diagnosis, treatment planning and monitoring as well as for educational and marketing purposes, including but not limited to lectures, webinars, presentations, printed materials and social media.  When used for view in the public, no identifying information will be revealed.

     

  • Informed Consent on Medication Use in Veterinary Behavior

  • Medications may be discussed or recommended in the course of treatment of behavioral problems.  Many of the medications prescribed in veterinary behavior have not been approved by the FDA (Food and Drug Administration) for use in all or any animal species for all or any behavior problems.  Thus, their use may be considered “off label”.  This is a legal, common and well-accepted practice for veterinarians to prescribe medications in this manner.  The side effects of off label usage have not been fully studied and regardless, any medication may have unexpected side effects.  Not all pets will require the use of medications as part of their treatment, but we want you to be aware of this information in advance.  We will make every effort to inform you of potential benefits and side effects of any medications recommended to the extent known. However, you should be aware that different pets may react differently to different medications.   We welcome any questions about the use of medications in your pet’s treatment plan.  By signing this form you acknowledge that you have received and read this information.   Signing this form in no way obligates you to using medications in the treatment of your pet.

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