New Patient Intake Form

Dr. Michele Broadhurst DC, CCSP, CCRP, CAC IVCA, FIAMA, MTech Chiro RSA
Doctor of Chiropractic, Certified in Animal Chiropractic by the International Veterinary Chiropractic Association & Certified Canine Rehabilitation Practitioner

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please download the intake form.

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New Patient Intake Form for Animal Chiropractic Care

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Cient (Your) Name *

First

Last

Email *

Home Address *

Mailing Address (if different from Home Address)

Home Phone Number

Cell Phone Number *

Referred By

Updates *

Permission to use text and/or email for communication, reminders, newsletter and updates
No thank you

Patient (Animal) Name *

Sex *

Male
Female

Intact *

Age *

Date of Birth *

Species *

Breed *

Color *

Weight *

lbs.

Veterinarian and Vet Clinic *

Treatment of Animal

Selected Value: 0

(1=very calm and friendly / 10=very aggressive)

Please explain your Treatment of Animal Selection *

Any Triggers and/or Fears? *

Reason for Seeking Chiropractic Care

How Did the Problem Occur and What Date? *

What Makes the Problem Better or Worse? *

How Would You Rate Your Animals’ Pain?

Selected Value: 0

On a scale of 0-10 (0 being no pain, 10 emergency level pain)

How Does Your Animal Show Their Pain (strange sounds, pacing, heavy breathing etc)?

Any Recent Diagnostics (bloods, MRI, x-rays) *

Trauma or Surgery & Date

Other Health Problems/Concerns/Illnesses

If so, please list the Clinics or Doctors seen for this condition(s), last time seen, and diagnosis)

Any Recent Changes in Behavior: (if so explain)

Description of Diet (also list known allergies), Frequency and Amount: *

Medications and Supplements *

Use/Job of Animal: *

Amount of Exercise, Type and Duration: *

Previous Chiropractic/ PT/ Rehab Care

(Name of Doctor and dates)

Additional Relevant Information

Informed Consent and Release *

I understand that by signing this I agree that I have disclosed all known issues about my animal to Functional Health Solutions DBA Rehab 4 Pets and believe that there are no underlying issues that I have not presented.
I understand that Dr Broadhurst is not a Doctor of Veterinary medicine and therefore I do not expect her to practice general veterinary medicine.
I have documented any behavioral issues that my animal may have towards people or other animals.
I understand and agree that FUNCTIONAL HEALTH SOLUTIONS DBA REHAB 4 PETS will not be held liable for any problems that may arise in the future and with the understanding that they are animals and are unpredictable, I hereby release FUNCTIONAL HEALTH SOLUTIONS DBA REHAB 4 PETS from any liability of any kind whatsoever with regards to my animal’s attendance and participation under FUNCTIONAL HEALTH SOLUTIONS DBA REHAB 4 PETS’s care.
I understand that I am solely responsible for any harm caused by my animal to any other animal or person or property while under FUNCTIONAL HEALTH SOLUTIONS DBA REHAB 4 PETS’s care. This includes any financial obligation that may result due to my animals’ behavior.
I understand and agree that I am responsible for paying 100% of the cost of a scheduled appointment if I cancel with less than 48 business hours’ notice.

Please select each box to indicate that you have read and understood the information

Photos & Video *

I grant FUNCTIONAL HEALTH SOLUTIONS DBA REHAB 4 PETS the right to take photographs or video of me and my animal. I authorize FUNCTIONAL HEALTH SOLUTIONS DBA REHAB 4 PETS to copyright, use and publish these in print or electronically. I agree that FUNCTIONAL HEALTH SOLUTIONS DBA REHAB 4 PETS may use such images with or without my name and for any lawful purpose including publicity, illustration, advertising or web/online content, webinars etc.

Informed Consent and Release *

I hereby allow FUNCTIONAL HEALTH SOLUTIONS DBA REHAB 4 PETS and my referring vet to share any and all records so they can better collaborate on my animal’s treatment. I allow FUNCTIONAL HEALTH SOLUTIONS DBA REHAB 4 PETS to share records with any and all members of my animal care team (I.e.: trainers, massage therapists, groomers, etc.). I hereby also allow use of my pet’s health information for research purposes to advance the field of animal chiropractic.
I understand that FUNCTIONAL HEALTH SOLUTIONS DBA REHAB 4 PETS is not a contracted provider with any insurance companies. My insurance policy is a relationship between myself and my insurer. Upon each service, I will be provided a detailed receipt that I may use for my own submission to my insurer. In submission, I understand there is no guarantee for reimbursement for services rendered and I do not hold FUNCTIONAL HEALTH SOLUTIONS DBA REHAB 4 PETS responsible for providing any records or receipts to my insurance company as they have provided them to me, the owner, directly.
I agree and realize that there are certain risks that are associated with alternative medicine, these have been explained to me and I understand them. I agree to release FUNCTIONAL HEALTH SOLUTIONS DBA REHAB 4 PETS from any liability arising due to unforeseen consequences of care and hereby waive any and all claims that may arise. I certify that I have read and understood this agreement and that the information set forth above is true and correct. I agree to all the terms, statements and conditions of this agreement.

Please select each box to indicate that you have read and understood the information.
1. Texas Administrative Code (573.14) Alternative Therapies – Chiropractic and Other Forms of Musculoskeletal Manipulation. May be performed by a licensed veterinarian, a non-veterinarian employee or independent contractor. Animal chiropractic and MSM may be performed under the following conditions: a valid veterinarian / client / patient relationship has been established as defined by the Act, an examination has been made by the licensee to determine that animal chiropractic / MSM will not likely be harmful to the patient, and the licensee obtains as a part of the patients permanent record a signed acknowledgement by the owner or other caretaker of the patient that animal chiropractic is considered by Texas law to be alternative therapy. A non-veterinarian employee or an independent contractor may perform these procedures on an animal under the “direct or general” supervision of the veterinarian.

Signature *

As the owner of the animal mentioned herin above, I have been made aware that animal chiropractic /musculoskeletal manipulation is considered by Texas law to be an alternative therapy. As the owner of the animal mentioned herin above, I have been made aware that acupuncture is an alternative therapy in veterinary medicine, and I am approving its use in my patient. I have been made aware of the conventional treatments available and their probable ability to cure the problem.
I do hereby authorize consent to treatment by Functional Health Solutions DBA Rehab 4 Pets for my pet’s injury or condition. I have been informed of the options and attending risks of hospitalization and treatment and understand the services stated. I acknowledge that I have provided Functional Health Solutions DBA Rehab 4 Pets with the necessary information requested. I agree to indemnify and hold Functional Health Solutions DBA Rehab 4 Pets harmless from and against any and all liability arising out of the performance of any procedures/treatment plans that will be performed or any adverse reactions occurring due to my nondisclosure of information.

Signed in agreement at the date and time this Sign Up form is sent.

Full Name as Signature *

First

Middle

Last

Please provide your full legal name as signature in agreement of the above.

Looking for the Vet Referral Form?

Download the Rehab 4 Pets Vet Referral Form.

Download Vet Referral PDF Form