Canine/Feline Therapy Client Info Form Owner / CaregiverPlease provide the information below as completely as possible. Items marked with an * are required to be answered. All information is strictly confidential.Pet's Name* Owner / Caregiver* Co-owner / Significant Other Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Preferred Phone*... Cell Home Office Additional Phone 1Additional Phone 2Email* How Did You Hear About Us? Pet InformationSpecies* Breed* Birthdate* Color / Markings Gender* Male Female Spayed or Neutered Yes No Weight* Is this a good weight? A little heavy? A little light? How old was your pet when you obtained? Where was your pet obtained? Referral InformationReferring Veterinarian Clinic Name Years you have been going there Pet HistoryOFA/Penn Hip Status (if known)Any AllergiesPet motivated by (food toys, etc)Brand of food given (including snacks/treats): Quantity of food: When fed: Supplements given (when and with amounts). Enter none if not on any supplements.*Medications given (when and with amounts): Enter none if not on any medications.*Does your pet have any major medical issues (past and/or present)?Has your pet undergone any surgical procedures (what and when)?Reasons for seeking our services:Duration and progression of current signs:Previous treatments and outcomes:Is the condition worse with: Hot Day After Exercising Wet Weather Cold Day After Resting/Sleeping Unknown Have you noticed anything else that aggravates this condition?Does your pet have any daily life restrictions caused by this condition?Have recent x-rays, blood work, or other diagnostics been performed for this current condition?Please list your goals for therapy:Activity / ExerciseWhat type and quantity of exercise does your pet do on a daily and weekly basis?Home EnvironmentDo you have stairs that your pet must go up/down?How many? Where are the stairs? Inside Outside Both Are the stairs carpeted? What type of flooring do you have in your house?Does your pet prefer to sleep on soft or hard surfaces? Soft Hard Either Neither Does your pet prefer to hot or cold places to sleep/lie down? Hot Cold Either Neither Does your pet have difficulty getting in and out of the car? Yes No Sometimes Do you have a ramp? Yes No Do you have a fenced yard? Yes No If yes, how big?Do you have other pets (please list)?Which of our services are you interested in? LASER Pulsed Signal Therapy Land Treadmill Hakomed Whirlpool Boarding Day Care/Day Play Play Pasture Rentals VSMT (Similar to Human Chiropractic) Therapeutic Massage Bodywork (Similar to Human Massage) Therapeutic Exercises Underwater Treadmill Sports Medicine Weight Loss Program All of the above Have you had Acupuncture done on yourself? Yes No Have you had Acupuncture done on your pets? Yes No Have you had Chiropractic adjustments made on yourself? Yes No Have you had (VSMT) Veterinary Spinal Manipulative Therapies (similar to human Chiropractic) done on your pets? Yes No Do you give Dr. Browne permission to perform gentle, hands on, spinal manipulations to your pet during the initial examination if she feels that it would be beneficial? Yes No To be discussed at exam Do you have any interest in Essential Oils?Do you have Pet Insurance? If so, which one?Additional InformationPlease give us any other information that you feel could be beneficial to us in helping your pet? If you are interested in sending us a home video of your pet for the doctor to review prior to your exam, please email to exec.asst@thera-vet.com. The Not So Fine PrintThera-Vet requires a $50 (administrative fee/deposit) in order to reserve an initial exam or recheck exam appointment with one of our Doctors. This deposit is applied toward the cost of your exam and it is refundable for cancellations or it is carried forward for rescheduling as a long as either of these events occurs 3 FULL BUSINESS days or more prior to your appointment. We typically will contact you 3 business days prior to your appointment to confirm, but regardless it is your responsibility to contact us in a timely manner if you do need to reschedule. Business days for Thera-Vet are Mon-Sat. If you call to cancel or reschedule your appointment inside of the 3 day window, your deposit will be forfeited and another $50 deposit will be required to reserve another appointment. Please also note that Thera-Vet requires a referral from your primary care veterinarian as well as a new client information form from you 3 days in advance of your appointment. Thera-Vet will contact your primary care Veterinarian for the referral, but it is solely your responsibility to get your new client information form to us as soon as possible. If we have any earlier openings, clients with all their paperwork in place are eligible to be moved up in our schedule. If we do not have all the required paperwork 3 full business days prior to your appointment, we will contact you to reschedule that appointment to avoid loss of your deposit.Please confirm that you have read, understand, and agree to our deposit policy. By checking this box you also confirm that you understand we reserve the right to postpone your appointment if we have not received all needed information at least 3 full days prior to your appointment.* I agreeCAPTCHA
