Please fill out ALL required fields marked with an asterisk * Intake Form For DogsDate* DD slash MM 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 We like to thank our referrals personally. What person or clinic referred you? Is your dog insured?* Yes No Does your insurance cover rehabilitation?* Yes No I'm not sure. Your Name* First Last Your Home Phone*Your Cell Phone*Your Email* Your Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Spouse/Partner Name First Last Your Partner's PhoneSecondary Email you would like on account: Regular Veterinary 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.Your Pet's InformationPrimary problem we are addressing:* Pet's Name Type Dog Cat Rabbit Other Breed Birthdate 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 No 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 No Prescribed medications, dosage and frequency.(ex: Rimadyl 25 mg–1 twice daily) separate by new line.Supplementsinclude: 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 No If Yes, Please Explain:Client RehabilitationWhat are your goals for rehabilitation for your pet: More comfortable from arthritis Better function/stronger Return to backyard games (ball playing, running with you) Weight loss Other If Other Honestly, how much time per day/ per week can you devote to rehab (we will adjust “homework” accordingly, so be honest.) 20 minutes - 2x/day 20 minutes daily 20 minutes every other day 20 minutess weekly 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 dog, is just as important as the exercises themselves. I can: Get on (and off) the floor with my dog Kneel and work with my dog without pain Walk my pet in uneven terrain Lift the front of my dog onto the couch Bend over my pet comfortably for 2 minutes while standing How often to you usually leash walk you dog? Daily 1-2 times per week Rarely How long (minutes) or how far (distance) do you go? Is this a motivated walk or a stop and sniff? Motivated walk Stop and sniff Are there inside stairs? (Check those that apply) Yes No Yes, but blocked Carpeted Hardwood Cement How many inside stairs are there? Are there stairs to get outdoors? (Check those that apply) Yes No Yes, but blocked Carpeted Hardwood Cement How many stairs to get outdoors are there? Is your dog leash trained (ie can he/she walk at heel?) Yes No Does your dog sleep on the bed? Yes No Is your dog allowed on the furniture? Yes No What flooring is in your house and where?Consent for Rehab Therapy - RESPONSES REQUIREDI 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 No I understand and agree that all payments are due when services are rendered.* Yes Release Section - RESPONSES REQUIREDI 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 Go to Veterinary AcupunctureThis 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. Federal regulations now require that we obtain permission for text messaging. We never spam our clients, text or otherwise. However, we do require you text or call when you arrive. Thus please accept text permission, the best communication about your pet.* Accept Reject Canceled Appointments Policy - RESPONSE REQUIREDSignificant 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. We will then use that $100 deposit toward the cost of your first visit. If the appointment is cancelled more than one week 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.. 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.* 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.* 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 $50. 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. CAPTCHAUntitled First Choice Second Choice Third Choice EmailThis field is for validation purposes and should be left unchanged. Δ
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