NEW CLIENT INTAKE FORM - CANINE

Dr. Paige Mott D.C., Karma, and the staff at Discover Life Chiropractic welcome you and

your animal family members!

We are happy that you have entrusted our office with the care of your pet. To provide you with quality, timely care, we need your cooperation with certain matters to ensure every client has his/her needs met.

PAYMENT:

Payment for services is due at the time of service. We accept cash, checks, MasterCard, Visa, Discover Card, and American Express. There is a $25 charge for any returned checks. Balances beyond 30 days will be charged an additional 1.5%. If an account is not paid within 90 days of the date of service, and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting your account.

PET FRIENDLINESS:

As the owner of your pet, it is your responsibility to inform the office staff if you pet does-not get along with other animals. Here at Discover Life Chiropractic we have an in-house dog that has free reign of the office. If this is going to be an issue at any time for you or your pet, please let the staff know prior to your arrival so that arrangements can be made. If your pet is not friendly with people, please inform the staff as we will have you bring you and your pet in through another entrance.

CONTROL AND BEHAVIOR OF YOUR PET:

As the owner of your pet, it is your responsibility to remain in control of your pet at all times. This includes but is not limited to, restraining your pet, muzzling (when necessary) etc. Should your pet become out of control, you as the owner are responsible for any damages. “Accidents” in the office happen, should your pet have an accident please let the staff know.

AUTHORIZATION: By signing below,

>You authorize the staff to perform any necessary services needed during diagnosis and treatment.

>You authorize Dr. P. Paige Mott/Discover Life Chiropractic to release any information concerning your pets physical condition which may be deemed appropriate and necessary to your pets veterinary doctor for combined treatment of your pet.

This is the entire agreement between Discover Life Chiropractic and the patient below. I have read this agreement, understand it and agree with its provisions. I received a copy of it at the time of signing it below.