Head to Tail Chiropractic | Intake and Consent Form

Intake and Consent form

Intake and Consent Form

Contact Us

OWNER INFORMATION

OWNER INFORMATION

Name:

Address:

City:

State:

Zip:

Phone:

Email:

How did you hear about us?

Animal Information

ANIMAL INFORMATION

Name:

Breed:

Age:

Sex:

Female

Male

Fixed

Current Veterinarian:

Health History

HEALTH HISTORY

Primary Complaint:

When did it start:

Did you see it happen?

Yes

Have you noticed similar symptoms before?

Yes

Have you seen a vet for these symptons?

Yes

Have you noticed any bowel/bladder habits and/or energy changes?

Current Medications/Supplements:

Type of Food:

Are your animal's vaccines current?

Yes

Type/frequency of exercise:

Any competitive activities?

Yes

Does your animal have any issues with...? (Check all that apply.)

other: (history)

Has this animal had any accidents / fractures / surgeries? If so, please describe.

Large Animals Only

LARGE ANIMALS ONLY

Date of last hoof trim:

shoed/barefoot

Shoed

Barefoot

Date of last dental checkup:

Free Text

Client Acknowledgement and Consent

Please note that these services are not a substitute for medical or veterinary care. If

your animal appears to be injured, please seek care of your veterinarian as soon as possible. By Arkansas Law, Any chiropractor licensed in this state and certified by the American Veterinary Chiropractic Association may perform chiropractic upon animals according to Ark. Code Ann. § 17-101-307. The undersigned acknowledges that Casie N. Ogden is cAVCA and currently licensed through the state of Arkansas.

Release and Hold Harmless

The undersigned assumes the unavoidable risks inherent in all animal-related activities including but not limited to bodily injury and physical harm. In consideration, therefore, as a client of Casie N. Ogden the undersigned does hereby agree to hold harmless and indemnify: Head to Tail Chiropractic PLLC and Casie N. Ogden and all employees and agents thereof, and further release them from any liability or responsibility for accident, damage, injury, or illness to the undersigned’s person or property.

Opt-In

I acknowledge that Casie N. Ogden at Head to Tail Chiropractic PLLC meets all the requirements to practice in the state of Arkansas.

Opt-In

I acknowledge that chiropractic/ musculoskeletal manipulation (MSM) is considered a form of alternative and complementary treatment/therapy and does not replace traditional veterinary medicine.

Opt-In

I acknowledge that I have stated and discussed all known medical conditions of this animal, and further, that I have answered all questions honestly. I also agree to keep Casie N. Ogden updated to any changes in the animal’s condition.

Opt-In

I acknowledge that a animal chiropractic adjustment, in rare cases, could lead to a temporary cause of swelling or soreness in both joint and musculature.

Opt-In

I understand and accept that appointments canceled less than 24 hours from the time of the appointment will incur the full consultation fee.

Opt-In

I understand and accept that consultation fees must be paid at the time of service and can be paid by cash, Venmo, or Zelle.

Opt-In

I understand by submitting this form, I am acknowledging my consent for my animal to wellness treatment by Head to Tail Chiropractic, PLLC, Casie N. Ogden.

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