New Client Info Form - Healing Arts Animal Care

New Client Information

Date*

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

We all have times that problems arise and cause the cancellation of an appointment at the last minute. It happens to everyone. But if it happens more than twice or more than one appointment is missed without notification, the full amount of that appointment will be billed to you. Clients who are more than 10 minutes late may be asked to reschedule. Please, just be considerate.

Initials*

By initialing, I agree to the cancelled appointment policy above.

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.