URL

This field is for validation purposes and should be left unchanged.

Intake Form For Dogs

Date*

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?

I understand that the services my pet is receiving are for conditioning and fitness of a healthy animal and are not considered veterinary rehabilitation or treatment of a medical condition. As such, I acknowledge that these services are not eligible for insurance reimbursement, and I agree not to submit them as a claim for coverage.

Your Name*

First Last

What are your preferred pronouns?

Your Home Phone*

Your Cell Phone*

Your Email*

Your Address*

Street Address City State ZIP Code

Your Spouse/Partner Name

First Last

Your Partner's Phone

What are your partner's preferred pronouns?

Secondary Email you would like on account:

Regular Veterinary Clinic

Preferred Veterinarian

City

** All invoices, receipts, 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

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

I will bring my own treats for my pet to use as motivation in the underwater treadmill. I understand that treats are necessary for motivation for many pets and an unmotivated pet does not get a proper work out.

Yes

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 responsibilities and Release of Liability

By my signature I certify that I have a Valid Veterinary Client Patient relationship with my referring veterinarian and they have examined this pet within the last year.*

Yes

Signature

I understand that the doctors at Healing Arts Animal Care will not be treating or diagnosing this pet.*

If I wish to convert my client status from referral for underwater treadmill, to rehabilitation under the doctors at Healing Arts Animal Care, I will notify the staff and will schedule a zoom and in person consult with one of our doctors.*

I certify that my electronic signature here is as valid as a written signature.*

I have fully read this consent information and understand its contents, implications and purpose.*

Underwater Treadmill Use Acknowledgment for Conditioning Purposes

I understand that the underwater treadmill sessions my pet is receiving at Healing Arts Animal Care are intended solely for conditioning and fitness purposes, and not for the treatment of any known or suspected medical condition.*

I acknowledge that 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.*

I further understand that the attending practitioner reserves the right to postpone or refuse treadmill use if they believe a medical evaluation or treatment is necessary prior to continuing with conditioning sessions.*

Cardiac Risk Acknowledgment for Conditioning Services

I agree that Healing Arts Animal Care is not liable for complications arising from pre-existing, undiagnosed, or undisclosed medical conditions, including cardiac disease.*

I understand that if my pet has undiagnosed heart disease, including but not limited to nutritional dilated cardiomyopathy (DCM) related to an unbalanced diet, physical activity such as underwater treadmill use may pose a risk of acute cardiovascular events.*

I acknowledge that Healing Arts Animal Care is not equipped to provide emergency medical care in the event of a cardiac or vascular crisis. Should such an event occur, I am responsible for immediately transporting my pet to the nearest emergency veterinary facility.*

Diarrhea Policy Acknowledgment

I understand that if my pet has experienced diarrhea within the past 72 hours, I am required to cancel or reschedule the appointment. If the cancellation is due to an acute illness, we appreciate your care and no cancellation fee will be charged. I understand that pets with diarrhea may pose a sanitation risk to the underwater treadmill system and a potential health risk to other patients, and that Healing Arts Animal Care must maintain a clean and safe environment for all animals.*

Poop in the pool rules:

I agree to ensure that my pet has urinated and defecated prior to their underwater treadmill session. While occasional accidents are understood, a fecal accident in the treadmill requires full sanitation, which may result in cancellation of subsequent appointments. I understand that there is a $100 cleaning fee for a fecal accident in the underwater treadmill. Each additional incident during the same session incurs an additional $100 fee. (ex $100 first time, $200 second time etc.). I acknowledge that it is my responsibility to be aware of my pet’s elimination habits and plan accordingly to help maintain a clean and safe environment for all patients.*

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. We will then use that $100 deposit toward the cost of your first visit. If the appointment is cancelled more than 14 days 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, 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.

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. For laser Patients we require a $50 deposit for the intial appointment. 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.*

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.

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.*

By initialing, 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.*