Chiro4Critters New Pet Appointment Form

Instructions

This form must be completed and submitted before you’re able to schedule an appointment with Dr. Kremer for a pet you’ve never brought in to see her.

Once this form is submitted, you will (instantly) be redirected to Dr. Kremer’s online schedule, where you can select and book an appointment for your pet.

Today's Date *

Address *

Country

City

State

Zip code

Your Full Name *

Your Cell Phone Number *

Email *

Email (please enter it once more for accuracy) *

Your Pet's Name *

Who is being seen?

Breed *

What breed is your pet?

Species *

Dog

Cat

Other

Pet Color *

Sex *

Male

Male, Neutered

Female

Female, Spayed

PET'S Date of Birth *

> CHOOSE YOUR ANIMAL'S BIRTHDAY < If you don't know the exact date, enter your best guess.

Last Veterinary Wellness Exam

Enter the date if known

If date is not known (Veterinary Wellness Exam)

Sometime within the past year

Unknown

Other

Pet's Veterinarian and/or Veterinary clinic *

Veterinarian's Office Email

Dr. Kremer will send her Initial Chiropractic report. PLEASE provide this!

Veterinarian's Office Phone Number *

In case Dr. Kremer wants to call if she has questions for the Vet.

Current Rabies Vaccination

Yes

Primary reason for visit today *

How long has this problem been going on? *

Has your pet been seen for the same condition recently? *

Yes

Any recent trauma that you are aware of?

Yes

Please explain the recent trauma

Has your pet had any X-rays? *

Yes

If "yes," please email them (with X-ray report) to drkremer@chiro4critters.com

List current medications and/or supplements

List past surgeries

Appetite

Increased

Normal

Decreased

Weight

Loss

Stable

Gain

Bowel Movements

Normal

Constipated

Diarrhea

Can't hold bowel

Weakness

None

Front End

Back End

Both (front & back)

Vomitting

Yes

Difficulty rising? *

Yes

Difficulty going up or down stairs?

Yes

List any recent behavioral changes

What does your pet get for exercise?

Previous Chiroparctic Care? *

Yes

How long ago was the previous chiropractic care?

More than a year ago

Within the last year

Within the last 6-months

More recently

Who performed the chiropractic care on your pet?

Please list any other health conditions your pet currently has or has had in the past

CHIROPRACTIC EXAMINATION & CARE CONSENT FORM

I, the owner/handler of the animal signing this form, and being eighteen years of age or older, do understand, substantiate, and authorize the following:

The purpose of chiropractic services is to promote natural health through the reduction of vertebral subluxation complexes (A misalignment of one or more vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of nerve impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential).

Since there are so many variables, it is difficult to predict the time schedule efficacy of the chiropractic procedures. Sometimes the response is phenomenal. Most often, there is a more gradual but quite satisfactory response. Occasionally, the results are less than expected. Two or more similar conditions may respond differently to the same chiropractic care and certain animals/breeds are predisposed to unfavorable health conditions and often respond unpredictably to chiropractic care. The fact is, that the science of chiropractic and medicine may never be so exact as to provide definite answers to all problems. Both have made great strides in alleviating pain and controlling disease.

An owner of an animal bringing the animal in to the doctor of chiropractic gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis and analysis. The chiropractic adjustment or other clinical procedure are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies, even certain health-challenged animals/breeds may render the patient susceptible to injury. It is the responsibility of the patient to make known or to learn through health care procedures whatever their animal is suffering from: latent pathological defects, illnesses or deformities which would otherwise not come to the attention of the doctor of chiropractic.

Chiropractic care is considered to be one of the safest and most effective forms of healthcare.

Acknowledgments: *

Dr. Amanda Kremer is a Doctor of Chiropractic, licensed in the care of humans. She has attended several hundred hours of education specific to Animal Chiropractic, and is Certified by the American Veterinary Chiropractic Association.

Dr. Amanda Kremer is NOT a Veterinarian, and cannot take responsibility for the primary care of my animal.

Chiropractic care IS NOT intended to replace appropriate Veterinary care, but intended to be used concurrently.

I realize there can be no guarantee as to the nature of my pet’s condition or the outcome of any procedure, and that the services are to only provide relief from everyday stresses put on the animal by performance.

I hereby authorize Dr. Amanda Kremer to adjust my animal with Animal Chiropractic. I certify that my animal has had regular veterinary care and is now concurrently being treated by the veterinarian listed above.

I also certify that I have been open and honest with Dr. Amanda Kremer as to any and all examinations, diagnostic tests, diagnosis, and treatments for my animal’s conditions. I have read this authorization form, and understand it and give my consent.

ALL boxes must be checked or your visit cannot be scheduled.

Signature *

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Reset Signature

Signature is required.

If referred, who was it that referred you?

So Dr. Kremer can personally thank them!

If you choose "Other" (above), how did you hear of Dr. Kremer?

Please share how you heard of Dr. Kremer...

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