Medium Animal

Health History Intake Form

This informed consent to cover the entire course of care from Georgia Animal Chiropractic, LLC., dba Douglas Animal Chiropractic for the treatment of present condition(s) and for any future condition(s) for which I seek chiropractic care for my animal. I hereby authorize Georgia Animal Chiropractic, LLC., dba Douglas Animal Chiropractic, to examine and provide chiropractic care to my animal(s) if there are no contraindications. I am/ will be honest with all the information that I provide and will share any other services, diagnoses, or examinations that my animal receives, and I verify that my animal is under current veterinary care.

Our animal chiropractors will review the intake form before an animal is seen. They will then take a health history and perform a physical examination to assess the animal's health and determine whether chiropractic care is appropriate.

I understand that if there is an emergency, I need to contact my veterinarian or an emergency veterinarian clinic/hospital, as Georgia Animal Chiropractic, LLC., dba Douglas Animal Chiropractic is not an emergency service.

Georgia Animal Chiropractic, LLC has explained its scope of practice and the procedures to be performed. They have explained the risks and benefits of treatment to my satisfaction. I understand that there is no guarantee about the nature of my animal’s condition or the resulting outcomes of treatment. I understand Georgia Animal Chiropractic, LLC’s intent is to do no harm, but I also understand that negative reactions to treatment can occur (such as but not limited to: fracture, dislocation, disc injury, strain/sprain, worsening of the present condition, stroke, or neurologic impairment.) I will indemnify and hold harmless Georgia Animal Chiropractic, LLC, and my referring veterinarian should any negative reactions occur.

CREDENTIALS:

I understand that employees of Georgia Animal Chiropractic, LLC., dba Douglas Animal Chiropractic are Doctors of Chiropractic (licensed in human health care) and are NOT veterinarians. These Doctors of Chiropractic have completed 240+ hours of animal chiropractic education through a postgraduate animal chiropractic-approved course. They are certified through the International Veterinary Chiropractic Association (IVCA) and will continue to stay up to date with animal chiropractic continuing education. These courses and certifications provide information and skills in order to safely and effectively adjust animals.

SCOPE:

The employees/contractors of Georgia Animal Chiropractic, LLC are NOT veterinarians, and they do not intend to replace traditional vet care or take responsibility for my animal's primary healthcare needs. I am seeking chiropractic for my animal(s) as a complementary therapy to be used concurrently with my current veterinary care. Animal Chiropractic and other forms of musculoskeletal manipulation are systems of therapeutic application of mechanical forces applied manually through the hands or any mechanical device to diagnose, treat, and or alleviate impaired or altered function of related components of the musculoskeletal system of non-human animals. Our services do NOT include dispensing/injecting medication, performing surgery, recommending supplements, or providing any traditional veterinary care.

THERAPIES TO BE USED:

I understand that my provider may use other therapies during the course of my treatment, which come with their own inherent risks. My provider reserves the right to use any of the therapies listed below during my care. The treatments and their possible reactions are listed below.

1. Cryotherapy: skin reactions

2. Heat: skin reactions, 1st/2nd degree burns

3. Traction: irritation of present condition, sprain/strain

4. Myofascial release/massage: localized tenderness, bruising, the release of emboli

5. Vibratory massage: deep vein thrombosis

6. Rehabilitation: aggravation of the present condition, blood pressure changes, increased heart rate

7. Red light therapy: releases toxins, can damage the retina, cannot be used on pregnancy, epileptics, implants, or cancers

8. Instrument-assisted soft tissue mobilization: bruising, redness, soreness, release of emboli, the release of toxins

9. Kinesiology tape: allergic reaction, skin irritation

Should I choose for my animal to NOT receive a certain therapy, or should their medical condition change, I will let my provider know during my treatment.

RECORD SHARING:

I hereby allow Georgia Animal Chiropractic, LLC., dba Douglas Animal Chiropractic, and my primary veterinarian to share any and all records so they may collaborate on my animal's care. I also agree to allow the sharing of records with any and all members of my animal care team (trainers, massage therapists, groomers, etc.). I also allow the use of my animal's health information for research purposes.

POST-TREATMENT EXPECTATIONS:

Many patients feel stiff, sore, or achy for a few days following their adjustment. This is common and expected. However, I understand that no medical procedure comes without risk. There can be side effects or complications which can arise during an adjustment that can include: fracture, dislocation, disc injury, strain or sprain, myelopathy, radiculopathy, organ/muscle paralysis, costovertebral strain or separation, and/or neurologic impairment. I understand that if there are underlying congenital and/or cardiovascular problems, some manipulations to the neck can contribute to injuries that may lead to serious complications, including stroke. These reactions, although rare, can happen.

DENIAL OF SERVICES:

I understand that my provider is allowed to deny services/treatment should there be a concern for my animal's well-being or a need for further diagnostic evaluation of their condition. I do not expect the provider to be able to able to anticipate and explain all risks and complications without the proper information. I understand it is my responsibility to tell my provider about any and all of my animal's medical history so they can make an informed decision when treating my animal. Shall I choose not to disclose my animal's full medical history, I assume full responsibility for what negative reactions may occur in reaction to treatment.

LIABILITY:

I understand that results are not guaranteed. I agree to hold my provider harmless for claims or damages in connection with my animal's treatment. This is a contract between myself and my provider, and I understand that it is also a release of potential liability. Georgia Animal Chiropractic, LLC has informed me that they carry malpractice and liability insurance. However, I understand that I am solely responsible for any harm caused by my animal to myself or any other animal, person, or property while under Georgia Animal Chiropractic, LLC's care. This includes any financial obligation that may result due to my animal's behavior.

FEES:

Georgia Animal Chiropractic, LLC., dba Douglas Animal Chiropractic has made me aware of their fee schedule. I agree to pay at the time of service for services rendered and for travel costs accrued. I do understand and consent that Georgia Animal Chiropractic, LLC., dba Douglas Animal Chiropractic may save my payment information and can charge cancellation fees if I do not cancel within 24-hour notice of my appointment. I understand that they can deny any future services if I have a credit on my account.

At Georgia Animal Chiropractic, LLC, our practice policies are designed to foster mutual respect and ensure the highest level of communication. This foundation enables us to work together effectively, helping your animal achieve optimal well-being.

SOCIAL MEDIA & TELECOMMUNICATION:

To maintain your confidentiality and minimize dual relationships, I do not accept personal friend or contact requests from current or former clients on any social networking sites (e.g., Facebook, LinkedIn). Adding clients as friends or contacts on these platforms could compromise both your confidentiality and our privacy, potentially blurring the boundaries of our therapeutic relationship. If you have any questions regarding this policy, please feel free to discuss them with me during our sessions.

For those interested, Georgia Animal Chiropractic, LLC., has official social networking pages where you can connect, follow, and interact with us. You can find us at @DouglasFamilyChiro and @DouglasAnimalChiro. We look forward to seeing you there!

SCHEDULING:

You can schedule appointments through our website or by calling our office at 706-290-3229. Once you're in our system, you'll also have access to texting capabilities. Due to time constraints, travel, and cellular limitations, we may not always be able to respond to emails or social media messages promptly, so please plan accordingly.

Our business hours for returning calls are Monday through Friday from 9 AM to 6 PM, and Saturdays on an emergency basis only. We do not respond to messages on Sundays or federal holidays.

To enhance efficiency and serve more animals, we offer house or barn calls only when we are already in your area, optimizing our travel routes and minimizing schedule gaps. If you need a specific appointment time, we will make every effort to accommodate your request. However, please understand that we may need to adjust your appointment to prioritize acute patients. Your flexibility is greatly appreciated, as we would extend the same consideration to your pet in times of need.

NEW PATIENT FORMS:

All vet referral forms and patient history must be completed before booking an appointment. Please fill out the health history intake forms to the best of your ability. Additionally, providing any photos, videos, medical notes, or diagnostic imaging prior to your appointment would be highly beneficial.

You can complete the forms online on our Forms page at DouglasFamilyChiro.com. Veterinarian records can be emailed to [email protected]. If you are unable to attend your animal's appointment and wish to discuss their care, please contact us at least 24 hours before the appointment.

COORDINATION OF CARE:

We are pleased to send your animal's case notes to the veterinarian on file. If you change your vet, kindly inform us promptly so we can update your animal's health record and ensure our notes reach the correct provider. For barns with multiple horse clients, we appreciate coordinating your animal's visits through a single point of contact, such as the barn manager or trainer, when possible.

MINIMUM TRAVEL REQUIREMENTS:

We value your animal's care, but in order to serve as many clients as possible, we cannot afford to travel to you unless we meet a minimum number of pets. Our travel radius, posted on our website, is roughly a one-hour drive time from Rome, GA.

1. If we are traveling 1+ hours, we require a minimum of 3 dogs or 2 horses.

2. If we are traveling 2+ hours, we require a minimum of 5 dogs or 3 horses.

3. If we are traveling 3+ hours, we require a minimum of 8 dogs or 5 horses.

4. We do not travel over 4 hours unless we have a list of over 10 animals with pre-payment.

*Animal head count is due within 72 hours of the reserved appt time.

PERSONAL SECURITY:

When you book a farm or house call, Georgia Animal Chiropractic, LLC reserves the right to take necessary measures to ensure the safety of its members, owners, employees, managers, officers, independent contractors, patients, and other affiliates while on the premises.

TERMINATION:

Ending relationships can be challenging. I may conclude your treatment after a thorough discussion and a formal termination process if I determine that professional boundaries are not being maintained, the treatment is not effective, or if there are payment defaults. I will not end our therapeutic relationship without first discussing the reasons and objectives for termination with you.

If treatment is terminated for any reason, or if you request a different provider, I will supply you with a list of qualified professionals for continued care. You are also free to choose another provider independently or through another referral source.

If you fail to schedule an appointment with me within one (1) year, and no prior arrangements have been made for legal and ethical reasons, I will consider our professional relationship discontinued.

PET INSURANCE:

I acknowledge that Georgia Animal Chiropractic, LLC, operating as Douglas Animal Chiropractic, is not a contracted provider with any insurance companies. My insurance policy constitutes a relationship solely between myself and my insurer. After each service, I will receive a detailed receipt, which I may use to submit a claim to my insurance company. I understand that reimbursement is not guaranteed, and I do not hold Georgia Animal Chiropractic, LLC,. dba Douglas Animal Chiropractic responsible for providing records or receipts directly to my insurance company, as these documents will be provided to me directly.

CANCELLATION & MISSED APPOINTMENT – LAST-MINUTE ADD-ON POLICY:

Please anticipate receiving text/email reminders about your upcoming appointment. You may unsubscribe from these reminders at any time. However, should you need to cancel, please give us at least 24 hours' notice (in-office appointment) or 72 hours' notice (house call) so we can adequately serve our growing waitlist. Should you not cancel within this window, a cancellation fee of 50% of services to be rendered will be charged to your account. In the event of a no-show appointment, and the chiropractor shows up to where my animal resides, full (100%) service and travel time charges will be applied and charged. In the event of a denied transaction using the payment information on file, we reserve the right to add your cancellation fee balance to your next visit. We store payment information securely using our payment processing application, which complies with all current data protection policies. You may request to have your payment information removed at any time. We require horse owners to pay a deposit within 3 days of your appointment. Should you cancel an appointment but not reschedule within one week of the cancellation, your deposit may take up to 30 days to be refunded. We may not always be able to accommodate last-minute add-ons. We need at least 72 hours notice of add-ons so we can make sure to provide a quality visit for you and your animal. Please notify our office within 24 hours should your animal be carrying a highly transmissible disease (ringworm, kennel cough, strangles, etc..) so we can make changes to your appointment as needed.

WHAT TO EXPECT:

When visiting our office, please arrive 5-10 minutes before your scheduled appointment and make sure your animal has pottied before arrival. If we are coming to you, we will send a message when we are en route. Please use potty pads or a diaper for animals with bowel or bladder control issues.

While we schedule appointments at specific times, allow a 15-20 minute window for any unforeseen delays. We will contact you directly if we are running behind. New patient consultations last about 30 minutes for small animals and 45 minutes to 1 hour for horses. Follow-up appointments are 15 to 20 minutes.

As we may not always have an assistant, your help in handling your animal may be required. If you are uncomfortable with this, please have a handler ready for house or barn calls. We may use restraint techniques (muzzle, chain, etc.) to facilitate treatment. If you have concerns, discuss them with us before your appointment. Note: no basket muzzles or prong collars on dogs, and no sedation for animals.

Bring your animal's favorite treat or incentive if they have food allergies and are nervous. For barn calls, provide a flat, level, and dry area (ideally shaded) for the appointment. Have your animal caught, free of mud, lightly groomed, and with feet picked 10 minutes prior to our arrival. Avoid show sheen, fly spray, or hoof oil.

For maximum effectiveness, allow your animal 1-2 days to rest and recuperate post-adjustment. We will send you (and your vet, upon request) a report of our findings within 5 days of service.

PAYMENT:

Payment is required at the time of service. We accept credit cards, cash, checks, and Venmo. If you cannot be present for the service, please ensure your payment information is saved on file before your visit. Should your payment fail, an invoice will be sent, with payment expected within three days of the service. Failure to settle the invoice may result in termination of our client relationship. Starting January 2024, all active clients must have a card on file to be charged in case of a no-call or no-show.

By signing below, I hereby acknowledge receipt of information concerning the Informed Consent and Practice Policies of Georgia Animal Chiropractic, LLC dba Douglas Animal Chiropractic. I understand it is my responsibility to be aware of and understand all policies and procedures. I also understand that guidelines and polices are subject to change and I am responsible for following the most recent version.