Please fill out ALL required fields marked with an asterisk * "*" indicates required fields Date* MM slash DD slash YYYY How did you hear about Healing Arts Animal Care?Google SearchVeterinary SurgeonVeterinary ClinicTrainerRescue OrganizationOther Animal ProfessionalA Friend/ClientOtherWe would like to thank our referrals personally. What person or clinic referred you?Client InformationYour Name* First Last What are your preferred pronouns?Your Home Phone*Your Cell Phone*Your Email* Your Address* Street Address City State / Province / Region ZIP / Postal Code Your Spouse/Partner’s Name First Last Your Spouse/Partner’s PhoneWhat is your spouse/partner’s preferred pronouns?Secondary email you would like on your account: Regular Veterinary ClinicPreferred Veterinarian**All invoices, receipts, appointment reminders and other correspondence will be sent via email, as we attempt to be an entirely green practice.Pet InformationPet’s Name First Type: Dog Cat Rabbit Other Other TypeBreedBirthdate Month Day Year Untitled Exact Approx Sex Male Female Neutered Spayed Used for Breeding Is your pet insured? Yes No Does your insurance cover rehabilitation? Yes No I’m not sure. Primary problem we are addressingWhat motivates your pet? Treats Toys Other Does your pet have food allergies, or dislikes that we need to know about? Yes No If yes, please explain:***Please bring your pet’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:Was your diet formulated by a veterinary nutritionist? Yes No Prescribed medications, dosage and frequency: (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, so we can all stay safe! Yes No If yes, please explain:Client Factors in 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 UntitledHonestly, how much time per day/week can you devote to rehab?(we will adjust “homework” accordingly, so please be honest.) 20 minutes – 2X/day 20 minutes daily 20 minutes every other day 20 minutes weekly Who in the household will be responsible for rehab?Knowing your abilities and limitations help us create an at home plan that is realistic for you and your pet. Protecting your body while working with your pet, 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 on uneven terrain Lift the front of my dog onto the couch Bend over my pet comfortably for 2 minutes while standing How often do you usually leash walk your 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 stairs at the home? (check those that apply) Yes Indoor Outdoors No Yes, but blocked Carpeted Hardwood Cement 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 type of flooring is in your home and where?Consent for Rehabilitation Therapy and Release of Liability Section-Responses RequiredUntitled* I elect to participate in my pet’s rehabilitation therapy, which may involve, but not be limited to the following: holding 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. Untitled* 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 agree 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. Untitled* 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, 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 muscle strains in myself or my pet. Untitled* 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. Untitled* I am responsible for disclosing any current or past medical issues affecting my pet. Healing Arts Animal Care and its practitioners are not liable for any consequences resulting from undisclosed medical conditions. Untitled* I further understand that the attending practitioner reserves the right to postpone or refuse service if they believe a medical evaluation or treatment is necessary prior to continuing with rehabilitation. Untitled* I acknowledge that Healing Arts Animal Care is not equipped to provide emergency medical care. Should such an event occur, I am responsible for immediately transporting my pet to the nearest emergency veterinary facility. Untitled* Healing Arts Animal Care uses AI tools to improve the accuracy of your pet’s records. All available security and privacy features have been enabled to protect information. We never use AI tools with your financial or personal data, simply pet health. However, as with any digital system, there is always a small risk of a data breach. Untitled* 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. Federal regulations require we obtain permission for text messaging. We never spam our clients, test or otherwise. However, we do require you to text or call when you arrive. Do you accept granting us text permission?*Federal regulations require we obtain permission for text messaging. We never spam our clients, text or otherwise. However, we do require you to text or call when you arrive. Do you accept granting us text permission? Accept Reject Untitled* I have fully read the consent for rehabilitation therapy and release of liability section and understand it’s contents, implications and purpose. Cancellation Policies-RESPONSE REQUIRED Zoom/Initial Exam Cancellations:Untitled* Significant time and resources are committed by Healing Arts Animal Care to prepare for your first visit for your 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 canceled more than 14 days prior to the appointment then it will be refunded to your credit card. If there is a late cancelation or a no show the deposit will be forfeited, even if it is rescheduled. 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. Therapy Appointment Cancellations: Healing Arts Animal Care is committed to providing all 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 are unable to keep your scheduled appointment. To cancel a Monday appointment, please contact our office by noon on Thursday. Call, text or email: (971) 703-3303 (appt@healingartsanimalcare.com) to notify us of any changes or cancellations. If 48 hours is not given, you will be charged $75 for the missed appointment. A punch on your rehab therapy card could be taken in leu of the $75 missed appointment fee.Untitled* By initialing, I agree with the above policy and payment of fees incurred through cancellation. Healing Arts Animal Care happily will take cash, checks, American Express, Discover, Visa, and Mastercard payments. There is a 3% processing fee added to all credit card payments. Payments made by debit card, cash, or check are eligible for a discounted rate. 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 al 10% per month billing fee, and non-payment is sent to collections at 90 days. There is a $75 returned check fee.By signing this statement, I signify that I agree and accept these financial conditions.*I have fully read this form and understand its contents, implications and purpose, and I certify that my electronic signature here is as valid as a written signature.* Δ
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