New Client Info Form - Healing Arts Animal Care

Please fill out ALL required fields marked with an asterisk *

New Client Information
Date*
Date Format: DD slash MM slash YYYY
How did you hear about Healing Arts Animal Care?
- Veterinarian Referral
- Friend Referral
- Online Search
- Other
Your Name*
First Last
Your Home Phone*
Your Cell Phone*
Your Partner's Phone
Your Email*
Your Address*
Street Address City State ZIP Code
Your Spouse/Partner Name
First Last
Secondary 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 Information
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.
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
- No
If Yes, Please Explain:
Client Rehabilitation
What 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
Is your dog leash trained (ie can he/she walk at heel?)
- Yes
- No
Are there stairs in your house, or to go out to go the bathroom? If so, how many?
Does your dog sleep on the bed?
- Yes
- No
Is your dog allowed on the furniture?
- Yes
- No
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
- No
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
Go to Veterinary Acupuncture
This authorization serves for today and further treatments unless revoked in writing.*
- Yes
Signature
By signing this statement, I signify that I agree and accept these conditions.
Canceled Appointments 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 as soon as possible if you won’t be able to keep an appointment. Call, text or email: (971) 703-3303 (healingartsvet@yahoo.com) by noon on the day 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 Friday. If prior notification is not given, you will be charged $75 for the missed appointment or a punch on your card. 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.
Initials*
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.
Initials*
By initialing, I state that I understand the new client deposit and cancellation policy..
Annual Physical Exam
Patients 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.
Initials
By initialing, I agree to annual physical exams and accept these finanical conditions.
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.
Signature
By signing this statement, I signify that I agree and accept these financial conditions.
Initials
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.

Please fill out ALL required fields marked with an asterisk *

New Client Information

Your Pet's Information

Client Rehabilitation

Consent for Rehab Therapy - RESPONSES REQUIRED

Release Section - RESPONSES REQUIRED

Canceled Appointments Policy - RESPONSE REQUIRED

Annual Physical Exam

FINANCIAL INFORMATION