New Patients

Application for Care

Prior to your initial visit, please complete the form below.

Name

Email Address

Home Phone

Mobile Phone

Address

City

State

Zip Code

Address

City

State

Zip Code

Animal's Name

Animal's Date of Birth

Animal Sex

Animal Breed

Animal Color

Primary Job/Discipline

Animal's Temperament

Purpose of Visit

Time of Injury

What Caused the Injury?

Name of Veterinarian

Vet Phone Number

Vet Email Address

Vet Address

City

State

Zip Code

Previous Surgeries

Medications/Supplements

Previous X-Rays/Results

Anticipated Outcomes of Treatment

Name

Date

CHIROPRACTIC EXAMINATION & TREATMENT CONSENT FORM AND WAIVER OF LIABILITY

I attest that I am the owner of the animal described in this intake form, or an authorized agent of the owner of such animal, and being eighteen years or older, do understand, authorize, and agree to the following: Dr. Tecla Fuller, DC, is a certified Animal Chiropractor by the Animal Chiropractic Certification Commission (ACCC) of the American Veterinary Chiropractic Association (AVCA). Additionally, she has received specialized training specific to Animal Chiropractic, and is therefore qualified to perform Animal Chiropractic services. I understand that chiropractic care IS NOT intended to replace appropriate veterinary care but intended to be used concurrently and with the knowledge and consent of my animal’s veterinarian. Alpine Animal Chiropractic has explained, and I understand the risks associated with, animal chiropractic therapy (which may include worsening of the condition) and proceed with an informed consent, releasing Alpine Animal Chiropractic, Dr. Tecla Fuller, and any other treating professional or employee associated with Alpine Animal Chiropractic, from all liability relating to or arising from these treatments. Treatment objectives, as well as the risks associated with chiropractic therapy and all other procedures provided at Alpine Animal Chiropractic, have been explained to me to my satisfaction and I have conveyed my understanding of both to the treating professional. I have been made no guarantee or warranty regarding the success of prescribed treatment, and that Alpine Animal Chiropractic cannot ethically provide such guarantee. I have been made aware that any positive effects of treatment may not be immediate and may require additional time and/or continued treatment. Regarding chiropractic adjustment, modalities, and therapeutic procedures, after careful consideration, I do hereby consent to treatment the doctor deems necessary or appropriate to treat my animal’s condition at any time throughout the entire clinical course of care. I understand the nature of therapies and treatments provided by Alpine Animal Chiropractic to be generally safe with minimal side effects. However, in the rare event that adverse effects require additional medical treatment, raising the cost above the previously discussed rate or requiring treatment from a veterinarian, I understand any and all associated financial costs are my sole responsibility. I agree that any representative of Alpine Animal Chiropractic, including Dr. Tecla Fuller, shall not be held liable for any consequential damages resulting from such care, direct or indirect. I understand that I am financially responsible for all services rendered by Alpine Animal Chiropractic and that full payment is due at the time of service. I agree and acknowledge I am financially obligated to pay any and all returned or declined check fees. I certify that I have read and fully understand the above terms and conditions concerning the treatment of the patient above as well as my financial obligations. I also certify that the information provided above in the Equine Application for Care is accurate and that I have the authority to execute this consent.

Name

Email Address

Home Phone

Mobile Phone

Address

City

State

Zip Code

Animal's Address

City

State

Zip Code

Animal's Name

Animal's Date of Birth

Animal Sex

Animal Breed

Animal Color

Primary Job/Discipline

Animal's Temperament

Purpose of Visit

Time of Injury

What Caused the Injury?

Name of Veterinarian

Vet Phone Number

Vet Email Address

Vet Address

City

State

Zip Code

Previous Surgeries

Medications/Supplements

Previous X-Rays/Results

Anticipated Outcomes of Treatment

Consent for Treatment

Date

CHIROPRACTIC EXAMINATION & TREATMENT CONSENT FORM AND WAIVER OF LIABILITY

Application for Care

Pediatric Application for Care

Additional Medicare Forms

(Complete if you have Medicare Insurance)

New Patients

Application for Care

Application for Care

Pediatric Application for Care

Additional Medicare Forms

Submit your forms