Intake Form For CatsDate* DD slash MM slash YYYY Where did you hear about Healing Arts Animal Care? Google search Veterinarian Surgeon Veterinary Clinic Trainer Other Animal Professional A friend/client Rescue Organization We like to thank your referrals personally. What person or clinic referred you? Client Information:Name:* First Last Home phone:*Cell phone:*Partner’s Phone:Email:* Address:* Street Address APT# City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Partner’s Name: First Last Secondary Email you would like on account: Regular Vet Clinic: Preferred Veterinarian: City: ** All invoices, receipts, exercise recommendations, appointment reminders and other correspondence will be sent by via email, as this attempts to be an entirely green practice.Pet’s Information:Primary problem being addressed:* Pet’s Name: Breed: Color: Current weight: (lbs.)Sex:* Male Female Neutered Spayed Used for breeding Birth Date:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Birth Date: Exact? or Approximate? Exact Approximate Declawed? Yes No Lifestyle? Indoor Outdoor Both Microchipped? Yes No Goal for rehab: Diet & Behavior:Diet type: Dry Wet Raw Homemade Human food Combo Dry Food Brand: How many cups of dry food per day? Wet Food Brand: How many cans of wet food per day? Size of wet food cans? Homemade diet consists of: Has your cat’s diet been formulated by a veterinary nutritionist? Yes No Prescribed medications, dosage, & frequency:(ex. Rimadyl 25mg- 1 twice daily. Separate by a new line) Supplements:(ex.Herbsvitamins, glucosamine, glandulars, homeopathics. Separate by commas.)Should we avoid giving your cat anything? (food allergies, dislikes, etc.)*if so, please bring your cat’s favorite treat or food to their appointment!May we offer your cat treats? Yes No Describe your cat’s personality, temperament, & special needs, if applicable.Does your cat have any behavioral concerns we should know about? Please be honest, this keeps us all safe!(ex. Friendly, shy, aggressive, fearful, unpredictable, biting, hissing, etc.) Please list any sensitive areas &/or favorite ways your cat likes to be petted.Lifestyle/Home:Is your cat allowed on the furniture? Yes No Does your cat jump on counters? Yes No Does your home have stairs, and does your cat use them? Yes No If so, how many stairs are there? Do you have hard wood floors in your house? Yes No Do you have any other pets in your home that your cat has contact with?How many litter boxes do you have in your home? Daily activity of your cat: Mild Moderate Active (ex. still playful, goes on walks, sleeps mostly, etc.)Estimated amount per day: Does your cat sleep in the bed with you? Yes No What motivates your cat?(ex. toys, treats, pets, verbal encouragement, etc.)Client Rehabilitation:What are your goals for rehabilitation for your pet: More comfortable from arthritis Better function/stronger Return to normal play activity Weight loss Other Other: Honestly, how much time per day/ per week can you devote to rehab 20 minutes daily 20 minutes every other day 20 minutes weekly (we will adjust “homework” accordingly, so please be honest). Who in the household will be responsible for rehab? Do you have children? What ages? Will they be a part of rehab at home? Knowing your abilities and limitations help me create a home plan that is realistic for your pet. Protecting your body while working with your cat, is just as important as the exercises themselves. I can:* Get on (and off) the floor with my cat Kneel and work with my cat without pain Bend over my pet comfortably for 2 minutes while standing Can your cat be trained/have you tried to train your cat before? Yes No What commands does your cat know? Consent for Rehab Therapy – RESPONSES REQUIRED:I elect to participate in my pet’s rehabilitation therapy, which may involve, but not be limited to the following: restraint of my pet, joint and limb manipulation, leash walking over obstacles, ultrasound, electrical stimulation, TENS, cold laser therapy, walking up and down hills or stairs and/or lifting and carrying my pet.* Yes I agree to hold the staff and veterinarians at Healing Arts Animal Care harmless from any and all liability or injury resulting from my decision to participate in my pet’s rehabilitation therapy. As a result of this decision I agrees to assume the risks, responsibilities and liabilities for the occurrence of any injury and or other mishap caused by my pet or while under my control at this facility.* Yes I understand that I will be given an at-home plan to continue my pet’s rehabilitation therapy at home under my sole care. I agree to hold the staff and veterinarians at Healing Arts Animal Care, Dr. Mandi Blackwelder, and Healing Arts Animal Care, LLC harmless from any and all liability including my own injury resulting from the care that I provide to my pet outside of this facility. This includes, but is not limited to bites from my pet and back, neck, or muscles strain in myself or my pet.* Yes 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.* Yes I have fully read this consent information and understand its contents, implications and purpose.* Yes 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.* Yes Release Section – RESPONSES REQUIRED:I hereby authorize Healing Arts Animal Care to perform acupuncture on my pet.* Yes No I have read the sheet/web page entitled “Veterinary Acupuncture” and understand the procedures, benefits, risks and possible side effects.* Yes This authorization serves for today and further treatments unless revoked in writing.* Yes By signing this statement, I signify that I agree and accept these conditions. Canceled Appointments Policy – RESPONSE REQUIRED:Significant time and resources are committed by Healing Arts Animal Care to prepare for my first visit for my pet. Records and x-rays are collected and extensively reviewed before you even come through our door. Therefore, there is a $100 deposit required for new clients. If the appointment is cancelled by noon the day prior to the appointment then it will be refunded to your credit card. If there is a late cancellation or no-show the deposit will be forfeited. We will then use that $100 deposit toward the cost of your first visit. Please note, this is simply a deposit toward the cost of the zoom call and initial appointment. If you choose not to attend the initial appointment, our time for preparation, consultation, and medical records will be billed at $150 per hour, generally much higher than the cost of the bundle. By initialing you agree to these charges.By initialing, I agree to the above policy and payment of fees incurred through cancellation. Significant time and resources are committed by Healing Arts Animal Care to prepare for my first visit for my pet. Records and x-rays are collected and extensively reviewed before you even come through our door. Therefore, there is a $100 deposit required for new clients. If the appointment is cancelled by noon the day prior to the appointment then it will be refunded to your credit card. If there is a late cancellation or no-show the deposit will be forfeited. We will then use that $100 deposit toward the cost of your first visit.* By initialing, I state that I understand the new client deposit and cancellation policy.* Annual Physical ExamPatients who are treated at Healing Arts Animal Care for over one year will need to have an annual physical exam with us. We need to do this once a year for all of our patients to stay in compliance with state law. The exam can be done at a regular visit and the fee is $75. If you have any concerns about this, feel free to talk to us about it.By initialing, I agree to annual physical exams and accept these financial conditions. FINANCIAL INFORMATIONHealing 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.By signing this statement, I signify that I agree and accept these financial conditions. 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. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
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