Animal Chiropractic New Patient Form

Owner's Name *

Today's Date

Date

Phone Number *

Area Code Phone Number

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email *

example@example.com

How did you hear about our Animal Chiropractic services? We are always sure to thank our referral sources. *

Friend/Family member Other Chiropractor/Veterinarian Google Facebook

How did you hear about our Animal Chiropractic services? *

Patient (Animal's) Name *

Age *

Date of Birth

Date

Gender *

Female Male

Neutered/Spayed *

Yes No

Species: *

Horse Dog Cat Goat Cow Rabbit

Upload a picture of your animal for our file please:

Browse Files

Breed *

Color *

Weight *

(lbs)

Height (for Horses only)

(hands)

Description/Markings on Animal: *

Temperament of animal (1=very calm and friendly, 10=aggressive; explain):

Any triggers/fears?

Reason for seeking Chiropractic Care?

Trauma or Surgery:

Health Problems/Concerns:

Any recent changes in behavior? (If so, explain)

Condition/Illnesses (List doctors seen for this condition, date last seen, diagnosis):

Description of Diet (also list known allergies):

Medications/Supplements:

Use/job of animal:

Previous Chiropractic Care (name of Doctor and dates):

By checking this box, I agree that I have read and understand the information below. *

I certify that I am the owner of the animal described above, and do understand, substantiate, and authorize the following: Dr. Danielle Reif is a Doctor of Chiropractic, licensed in the care of humans. She has attended several hundred hours of education specific to Animal Chiropractic, and has been certified in Animal Chiropractic by Parker University. Dr. Danielle Reif IS NOT a veterinarian and cannot take responsibility for the primary care of my animal. Chiropractic Care IS NOT intended to replace traditional veterinary care, but is considered a complementary therapy, to be used concurrently and in conjunction with my veterinarian’s care. Dr. Danielle Reif has explained the risks involved with the Animal Chiropractic care to my satisfaction, and I realize that there can be no guarantee as to the nature of my animal's condition or the outcome of any procedure. In order to properly evaluate an animal patient, it is necessary to have any diagnostic information available from the primary veterinarian. I agree to furnish such information, including radiographs, to Dr. Reif for the purpose of evaluating my animal for chiropractic care. Dr. Reif agrees to return such information as soon as possible. Follow-up reports will be provided to my veterinarian upon his/her request. I give Dr. Reif permission to release information concerning the care of my animal for the purpose of such reports when requested. I hereby authorize Tulsa Healing, and in particular, Dr. Danielle Reif, Certified Animal Chiropractor, to treat my animal with Animal Chiropractic. I certify that my animal has had routine, and traditional veterinary care. I certify that I have been open and honest with Dr. Reif as to any and all other examinations, diagnostic tests, diagnoses. and treatments for my animal's conditions. I have read this authorization form, understand it, and give my consent.