Owner One First Name Last Name Owner Two First Name Last Name Contact Information Primary Phone Secondary Phone Email Street City State Select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Preferred Way of Contact Primary PhoneSecondary PhoneEmailText Who is your family veterinarian? Pet's Information Pet's Name Breed Color Age/DOB (date) Sex MF Spayed/Neutered? YesNo Pet Insurance? YesNo If yes, What company? Is your pet currently on any medications? Please list name, dose, frequency, and how long they have been on the medication: Is your pet currently taking any supplements? YesNo What BRAND of food and quantity? Why did you bring your pet in to see us today? Does your dog have any behavioral concerns we should be aware of? Please explain: Dog Bite Information Has dog been trained in bite work? YesNo Does your dog have a bite history? YesNo If you answered "yes" to either of these questions, your dog may need to be muzzled for treatment. Authorization to Provide Care/Treatment: I am the owner or authorized agent of the owner of the pet listed above, hereby and direct the physical therapists/veterinarians of SPAR or their assistants to perform all rehabilitation assessment and treatments within accepted physical therapy guidelines as deemed advisable and/or necessary for my pet. I authorize SPAR to obtain all medical records regarding my pet as is necessary for the thorough and complete evaluation and treatment of my pet. I understand that portions of my visit may be recorded for educational and promotional purposes. I understand that there is no guarantee, nor can one be made as to the results or cure of any therapy. I understand that the physical therapists/veterinarians of SPAR recommend therapy and treatment options but that other persons may have different opinions about what therapies and treatments are necessary or appropriate. I understand that I have a choice to obtain additional information regarding those opinions from SPAR upon my request or I may research the different opinions about therapies and other care myself and discuss my questions with my veterinarian/physical therapist. I agree to pay, in full, for services rendered. I understand that payment is due at the time services are rendered. If for any reason payment is not made at the time services are rendered or within 10 days thereafter, I understand that my account may be referred to a collection agency. In the event that my account is referred to a collection agency, I agree that SPAR may add an amount to my outstanding account balance to reimburse SPAR for the reasonable collection charges (but not including attorney’s fees) imposed by the collection agency. I understand that SPAR will take reasonable precautions to ensure the safety of my pet while in their care. I agree to hold harmless SPAR their owners, employees, and agents from any and all liability of any nature, loss or injury to self, loss or injury to family including pet, loss or injury to guest as a result of participating in any SPAR assessments, treatments, classes and programs. I personally assume all liability for the care of my pet while under the care of SPAR. SPAR Appointment Cancellation/No Show Policy Pet's Name Thank you for trusting us with your pets' care and wellbeing. When you schedule an appointment with SPAR, we set aside enough time to provide you and your pet with the highest quality care. Should you need to cancel or reschedule an appointment please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment. SPAR does not make reminder calls for appointments so please take note of what you schedule and feel free to always call/text to confirm appointment dates and times. We understand there may be times when an unforeseen emergency occurs, and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances, please contact the office (regardless of time of day), if unanswered please leave a message. I have read and understand the SPAR Appointment Cancellation/No Show Policy and agree to its terms. Signature Date
