Client Massage Referral Form

Veterinary rehab massage is a specialized therapeutic technique designed to enhance the recovery and overall well-being of animals. This form of massage aids in reducing pain, improving circulation, and promoting flexibility in injured or aging pets. By using targeted techniques, veterinary professionals can help alleviate muscle tension, enhance mobility, and support rehabilitation after surgery or injury. Regular sessions can also benefit athletes, helping to maintain peak performance and prevent injuries. Ultimately, veterinary rehab massage fosters a stronger bond between pets and their owners while ensuring a more comfortable, healthier life for our furry companions.

"*" indicates required fields

Date*

MM slash DD slash YYYY

From who did you hear about Healing Arts Animal Care?

Google Search

Veterinarian Surgeon

Veterinary Clinic

Trainer

Other Animal Professional

A friend/client

Rescue Organization

Other

We like to thank our referrals personally. What person or clinic referred you?

Is your dog insured?*

Yes

Does your insurance cover rehabilitation?*

Yes

I'm not sure.

Your Name*

First Last

Your Home Phone*

Your Cell Phone*

Your Email*

Your Spouse/Partner Name

First Last

Your Partner's Phone

Your Partner’s Preferred Pronouns

Your Partner's Phone

Secondary Email you would like on account:

Regular Veterinary Clinic

Preferred Veterinarian

City

** All invoices, receipts, appointment reminders and other correspondence will be sent by via email, as this attempts to be an entirely green practice.

Your Pet's Information

Primary problem we are addressing:*

Pet's Name

First

Type

Dog

Cat

Rabbit

Other

Breed

Birthdate

MM slash DD slash YYYY

Birthdate Exact/Approx

Exact

Approx

Sex

Male

Female

Neutered

Spayed

Used for Breeding

What motivates your pet?

Treats

Toy

Other

Does your pet have food allergies that we need to know about?

Yes

If Yes, Explain Allergies

*** Please bring your dog’s favorite treat broken into small bits with you.

My Pet Eats

Dry Food Brands

Wet Food Brands

Treats of Human Food

Dog Treats

Homemade diet

If Dry Food, What Brand?

How Many Cups of Dry Food per Day?

If Wet Food, What Brand?

How Many Cans per Day and What Size Cans?

Homemade diet consists of:

If so, was your diet formulated by a veterinary nutritionist?

Yes

Prescribed medications, dosage and frequency.

(ex: Rimadyl 25 mg–1 twice daily) separate by new line.

Supplements

include: herbs, vitamins, glucosamine, glandulars and homeopathics. Separate by commas.

Does your pet have any behavioral problems (fear, biting or jumping up) that we need to know about? Please be honest, this keeps us all safe!

Yes

If Yes, Please Explain:

Consent for Massage Therapy - RESPONSES REQUIRED

Release of liability:

By my signature I certify that I have a Valid Veterinary Client Patient relationship with my referring veterinarian and they have examined this pet within the last year. I also certify that my electronic signature here is as valid as a written signature.*

Yes

Signature*

I understand that the doctors at Healing Arts Animal Care will not be treating or diagnosing this pet. The pet will be treated by a highly trained veterinary assistant or technician in areas prescibed by your veterinarian. If the staff feels other areas need treatment, they will contact my veterinarian to amend the prescription.*

I certify that I have not been made any medical promise of success or guarantee of outcome of service. I understand that every medical condition is different and outcomes are based upon multiple factors.*

I have fully read this consent information and understand its contents, implications and purpose.*

I give permission for photos/videos of my pet and their health story to be used for social media, speaking engagements, and promotional materials for Healing Arts Animal Care.*

Yes

I understand and agree that all payments are due when services are rendered.*

New Clients Policy - RESPONSE REQUIRED

There is a $50 deposit required for new clients. We will then use that $50 deposit toward the cost of your first visit. By initialing below you agree to these charges. (if applicable)

Initials*

Cancelation Policy – RESPONSE REQUIRED

Healing Arts Animal Care is committed to providing all of our patients with exceptional care. When patients cancel without giving enough notice, they prevent another patient from receiving care. We understand that sometimes emergencies happen. Please let us know at least 48 hours before if you won’t be able to keep your scheduled appointment. Call, text or email: (971) 703-3303 (appt@healingartsanimalcare.com) at least 48 hours prior to your scheduled appointment to notify us of any changes or cancellations. To cancel a Monday appointment, please call our office by noon on Thursday. If 48 hours notice is not given, you will be charged $75 for the missed appointment or a punch on your card. Thank you!!! By initialing, I agree to the above policy and payment of fees incurred through cancellation.

Initials*

FINANCIAL INFORMATION

Healing Arts Animal Care happily will take cash, check, American Express, Discover, Visa and Mastercard for payments. Payment is always due at the time of service. There is no billing permitted for services. If payment is not received at the time of service there is a 10% per month billing fee, and non-payment is sent to collections at 90 days. There is a $30 returned check fee.

I understand that by initialing that this constitutes a legal signature confirming that I acknowledge that the above information is true and agree to the above terms and releases of liability.*

Yes

By initialing, this constitutes a legal signature confirming that I acknowledge that the above information is true and agree to the above terms and releases of liability.*

By signing this statement, I signify that I agree and accept these financial conditions.*

Yes

Signature

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