Patient Intake Form

New Patient Intake form:

Premier Animal Wellness
Owners Name

First NameLast Name
Address

Street Address

Street Address Line 2 /Unit no.

CityState

Postal / Zip Code
Cell Number
Format: (000) 000-0000.
E-mail
Animals Name

First NameLast Name
Date of Birth

DayMonthYear
Age
Species:
Breed:
Gender
Weight:
Color/Markings:

Has Your Animal Experienced Any of the Following :

Rows	YES	NO	Comments
Lameness
Arthritis
Performance Issues
Difficulty Turning/Bending
Difficulty Laying Down
Back Pain
Neck Pain
Stiffness
Neurological Issues
Change in Posture
Separation Anxiety
Sleep Issues
Loss of Appetite/Dietary Change
Low Energy/Fatigue
Change in Gait/Stride
Uneven Muscle Tone

List Your Primary Goals for Chiropractic Care:
Current Medications and Supplements- Please Describe :
Any previous surgeries, Injuries, or Diagnoses- Please Describe :
Informed Consent:

I voluntarily request chiropractic evaluation and care for my animal through Premier Animal Wellness.

I understand and acknowledge the following:

• Animal chiropractic care is intended to support proper motion and function of the musculoskeletal and nervous systems.

• Animal chiropractic care is not veterinary medicine and does not replace veterinary diagnosis, treatment, medications, surgery, or emergency care.

• Dr. Jen Santa Maria, DC, does not diagnose disease, prescribe medications, perform surgery, or provide veterinary medical treatment.

• Results vary between animals, and no guarantees regarding outcomes have been made.

• Temporary soreness, fatigue, stiffness, or behavioral changes may occasionally occur following care.

• If my animal experiences illness, injury, worsening symptoms, or emergency conditions, I will seek veterinary care immediately.

I have read and understand the informed consent above.
Signature
Date

MonthDayYear
Liability Release:

I understand that animals may react unpredictably during handling, examination, and treatment.

I accept responsibility for my animal’s behavior and agree to disclose any known health concerns, injuries, behavioral issues, or aggressive tendencies.

To the fullest extent permitted by law, I release and hold harmless Premier Animal Wellness, Dr. Jen Santa Maria, DC, and its representatives from claims arising from participation in animal chiropractic services except in cases of gross negligence or willful misconduct.

I understand and agree to the liability release above.
Signature
Date

MonthDayYear
How did you hear about us?
May Premier Animal Wellness use photos or videos of your animal for educational, marketing, or social media purposes?
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New Patient Intake form: