Intake Forms for all Chiropractic Patients

Please complete one intake for each individual patient

The intake forms below are for all the different types of patients we are able to treat. Each form is loaded into the patient's profile for notes, and records. To enter another intake, please click here after your previous entry has been confirmed.

Intakes are required for all new patients and patients that haven't been seen in 2+ years. Please have the appropriate intakes completed 24 hours prior to your appointment! Please do not enter an intake without scheduling an appointment or calling/texting us. Not having the intake done prior to your appointment will cause delays in the doctors schedule!

Equine Intake Form

Equine Intake Form:

Animal Owners Name(Required)

Primary name you would like the patient file, reports, and contact info under. Please enter one persons name here.

First Last

Who's contact info is listed below?(Required)

Animal Owners

Other Contact

Contact name other than owner(Required)

Enter a contact name if it is DIFFERENT from the owners name. This would be like a trainer or boarder that has authorization from the owner to make decisions regarding the animals care.

First Last

Phone(Required)

Email(Required)

Animal's name(Required)

Animal's location(Required)

Where the animal is stabled/resides at.

Street Address City State ZIP Code

Animal's Date of Birth(Required)

If you don't know the birth date please enter a date you would like to use as the birth date.

Month

Day

Year

Sex:(Required)

Colt

Filly

Gelding

Mare

Stud/Stallion

Species(Required)

Color of animal(Required)

Breed(Required)

Primary job/discipline(Required)

Animal's Temperament(Required)

How would you describe the animals behavior?

Stands still for most everything with no problems

Stands for farrier but might have a tendency to move around

Better watch out...animal easily scares/spooks

Temperament Concern: There will likely be limitations in adjusting an animal that easily scares or spooks. The doctor uses a bale, like a mounting block, during the exam and adjustment. If your animal is frightened of a mounting block they might have issues with the adjusting block. Please try and work with them, before the appointment, for the safety of the animal, yourself, and the doctor.

Purpose of visit:(Required)

New Problem/Exacerbation

Maint/Checkup Observed issues and/or concerns

Time of injury

Hours

Minutes

AM/PM

What caused the injury

Would you like to provide your Veterinarians Information?(Required)

Yes

No thank you

Name of Veterinarian(Required)

First Last

Veterinarian Phone Number(Required)

Veterinarian Email(Required)

Veterinarian Address

Street Address Address Line 2 City State ZIP Code

Surgeries

Medications or supplements

Previous Xrays(Required)

less than 6 months

greater than 6 months

none/NA

Regions for xray

xray findings

Who is consenting to treatment?(Required)

First Last

Chiropractic Examination and Treatment Consent(Required)

Chiropractic Examination and Treatment Consent Form:

I attest that I am the owner of the animal described in this intake form, or an authorized agent, and being eighteen years or older, do understand, substantiate, and authorize the following:

The purpose of chiropractic services is to promote natural health through the reduction of intervertebral joint restrictions (a lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. The result of this can additionally cause alteration of nerve function and interference to the transmission of nerve impulses, resulting in a lessening of the animal’s innate ability to express its maximum health potential).

Since there are many variables, it is difficult to predict the duration and frequency required for the recommended chiropractic procedures. It’s not uncommon for the response to animal chiropractic to be phenomenal. Most often, there is a more gradual but quite satisfactory response. Rarely, the results are less than expected, although there’s always that potential. 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 (or more commonly, less favorably) to chiropractic care. The fact is, the science of chiropractic and medicine may never be so exact as to provide definitive 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 or the doctor making house/barn calls, gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis, analysis and procedures. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problems. 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 proven to be one of the safest and most effective forms of healthcare available.

Dr. Stephanie B. Parent, D.C., ACCC/AVCA is a Doctor of Chiropractic, licensed in the care of humans and animals through the state of Colorado, and is certified in Animal Chiropractic by the Animal Chiropractic Certification Commission (ACCC) of the American Veterinary Chiropractic Association (AVCA). Additionally, she has received specialized training specific to Animal Chiropractic, and is therefore qualified to perform animal chiropractic services.

Dr. Stephanie B. Parent, D.C., ACCC/AVCA is NOT a veterinarian, and cannot take responsibility for the primary care of my animal. According to Colorado laws for animal chiropractic, the treating veterinarian is required to be present during the treatment for all animals except equid and canine.

Chiropractic care IS NOT intended to replace appropriate veterinary care, but intended to be used concurrently.
I have read and understand the scope of the animal chiropractic care my pet will receive. I understand and acknowledge and agree with the College of Animal Chiropractors description of Animal Chiropractic as follows: “Animal Chiropractic is the examination, diagnosis, and treatment of non-human animals through manipulation and adjustments of specific joints and cranial sutures”. Animal Chiropractic DOES NOT include: dispensing of medications, performing surgery, injecting medications, laser treatments, taping, recommending supplements or replacing traditional veterinary care.

I realize there can be no guarantee as to the nature of my pets condition or the outcome of any procedure, and that the services are to only provide relief from those which are within the scope of animal chiropractic, as defined above.

I hereby authorize Dr. Stephanie B. Parent, D.C., ACCC/AVCA to adjust my animal with Animal Chiropractic. I certify that my animal has had regular veterinary care.

I consent to treatment

CAPTCHA

Canine Intake Form

Canine Intake Form:

Owners name*
Phone*
Email*
Owner's birthday

We enter the owners information, like date of birth, into our electronic health records for accurate information. If no date is provided, we use the date of initial service. This information is used when scheduling online for human chiropractic visits.
Owner's Address*
Street Address Address Line 2 City State ZIP Code
Animal's name*
Species
Breed*
Color of animal*
Primary job/discipline*

Does the animal have a job or discipline? This would be something like a service dog, military or police, special training, or a companion animal.
Sex:*
- Male
- Female
Is the animal Spayed or Neutered?*
- Yes
- No
Date of Birth*
MM slash DD slash YYYY
Purpose of visit:*
- New Problem/Exacerbation
- Maint/Checkup Observed issues and/or concerns
Time of injury

: Hours

Minutes

AM/PM
What caused the injury
Name of Veterinarian
First Last
Veterinarian Phone Number
Veterinarian Email
Veterinarian Address
Street Address Address Line 2 City State ZIP Code
Surgeries
Medications or supplements
Previous Xrays
- less than 6 months
- greater than 6 months
- none/NA
Regions for xray
xray findings
Chiropractic Examination and Treatment Consent*
Chiropractic Examination and Treatment Consent Form:

I attest that I am the owner of the animal described in this intake form, or an authorized agent, and being eighteen years or older, do understand, substantiate, and authorize the following:

The purpose of chiropractic services is to promote natural health through the reduction of intervertebral joint restrictions (a lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. The result of this can additionally cause alteration of nerve function and interference to the transmission of nerve impulses, resulting in a lessening of the animal’s innate ability to express its maximum health potential).

Since there are many variables, it is difficult to predict the duration and frequency required for the recommended chiropractic procedures. It’s not uncommon for the response to animal chiropractic to be phenomenal. Most often, there is a more gradual but quite satisfactory response. Rarely, the results are less than expected, although there’s always that potential. 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 (or more commonly, less favorably) to chiropractic care. The fact is, the science of chiropractic and medicine may never be so exact as to provide definitive 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 or the doctor making house/barn calls, gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis, analysis and procedures. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problems. 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 proven to be one of the safest and most effective forms of healthcare available.

Dr. Stephanie B. Parent, D.C., ACCC/AVCA is a Doctor of Chiropractic, licensed in the care of humans and animals through the state of Colorado, and is certified in Animal Chiropractic by the Animal Chiropractic Certification Commission (ACCC) of the American Veterinary Chiropractic Association (AVCA). Additionally, she has received specialized training specific to Animal Chiropractic, and is therefore qualified to perform animal chiropractic services.

Dr. Stephanie B. Parent, D.C., ACCC/AVCA is NOT a veterinarian, and cannot take responsibility for the primary care of my animal. According to Colorado laws for animal chiropractic, the treating veterinarian is required to be present during the treatment for all animals except equid and canine.

Chiropractic care IS NOT intended to replace appropriate veterinary care, but intended to be used concurrently.
I have read and understand the scope of the animal chiropractic care my pet will receive. I understand and acknowledge and agree with the College of Animal Chiropractors description of Animal Chiropractic as follows: “Animal Chiropractic is the examination, diagnosis, and treatment of non-human animals through manipulation and adjustments of specific joints and cranial sutures”. Animal Chiropractic DOES NOT include: dispensing of medications, performing surgery, injecting medications, laser treatments, taping, recommending supplements or replacing traditional veterinary care.

I realize there can be no guarantee as to the nature of my pets condition or the outcome of any procedure, and that the services are to only provide relief from those which are within the scope of animal chiropractic, as defined above.

I hereby authorize Dr. Stephanie B. Parent, D.C., ACCC/AVCA to adjust my animal with Animal Chiropractic. I certify that my animal has had regular veterinary care.
I consent to treatment
CAPTCHA

Human Intake Form

Patient's name*
First Last
Patient's date of birth*
Is patient a minor?*
- Yes
- No
What is the name of the parent/guardian?*
First Last
Phone*
Phone type*
- Cell
- Home
Email*
Patient's Address*
Street Address Address Line 2 City State ZIP Code
Gender:*
- Male
- Female
Height
Weight
Marital Status
- Single
- Married
- Divorced
- Widowed
Name of Spouse
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone*
How did you hear about us?
Family Physician
Physician Phone
Date of Last Visit with Family Physician
Month
Day
Year
Work Status
- Full Time
- Part Time
- Disability
- Student
- Retired
- Unemployed
Have you missed work or school due to this injury?
- Yes
- No
Occupation
The Symptoms that have prompted you to seek care today include:*
Have you seen other doctors for this condition?*
- Yes
- No
Prior Interventions
- Acupuncture
- Chiropractic
- Heat
- Homeopathic
- Ice
- Massage
- Medication
- OTC Meds
- Physiotherapy
- Surgery
- Other
What is the condition related to?*
- Auto Accident
- Home Injury
- Sports Injury
- Work Injury
- Other
When did your problem first start?*
Month
Day
Year
Have you had this condition before?*
- Yes
- No
Does the pain radiate or travel to other parts of the body?*
- Yes
- No
Does anyone from your family suffer from the same condition?*
- Yes
- No
What makes the condition worse?*
- Select All
- Bending
- Coughing
- Defecation
- Lifting
- Sitting
- Sneezing
- Stairs
- Standing
- Walking
- Other
What makes the condition better?*
- Select All
- Bed Rest
- Heat
- Ice
- Massage
- Medication
- Other
Does this condition affect employment?*
- Yes
- No
Does this condition affect recreation?*
- Yes
- No
Does this condition affect sleep?*
- Yes
- No
What else should we know about your current condition?
Rate the severity of your pain from 0 to 10*
Please enter a number from 0 to 10.
Pain Duration*
- Constant
- Intermittent
Current Medications
- Blood Pressure
- Insulin
- Muscle Relax
- Nerve Pills
- Pain
- Other
Supplements
- Yes
- No
Previous Xrays*
- less than 6 months
- greater than 6 months
- none/NA
Regions for xray
Areas experiencing pain
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Sensory
Integumentary
Endocrine
Genitourinary
General
Personal Illness History
Surgery/Trauma History
Fractures*
- Yes
- No
Auto Accident*
- Yes
- No
Spinal Injury*
- Yes
- No
Hospitalization*
- Yes
- No
Alcohol Use
Coffee Use
Tobacco Use
Exercise
Pain Reliever
Water Intake
Significant Family History
Chiropractic Examination and Treatment Consent*
PLEASE READ CAREFULLY In order for Doctor Stephanie Parent to make a determination on the suitability of my case for chiropractic care, I acknowledge and understand that I must complete a thorough chiropractic evaluation, which may include a diagnostic radiographic examination if clinically indicated. I do hereby request and consent to the performance of such an evaluation by the Chiropractor indicated below, or any party authorized to do so by that Chiropractor.

I have had the opportunity to discuss with Doctor Stephanie Parent or with any party authorized to do so by that Chiropractor, about the nature and purpose of Chiropractic adjustments and other procedures. I understand that Chiropractic care is considered very safe with an extremely low-risk rate. I further understand that there are, however, some risks associated with chiropractic care, as there are with any and all healthcare treatments. In healthcare, the matter of whether any treatment is appropriate or not is determined by looking at the level of risk and comparing this with the level of expected benefit.

In particular, I understand that in rare cases there have been reported incidents of injury to the vertebral artery during the course of care to the cervical spine by medical doctors, physiotherapists, and chiropractors. However, the proposed mechanism of this injury is reproduced by a wide variety of trivial neck movements, including turning your head to look out the back of a car, or having a shampoo at a hair salon. This injury is of concern because it may lead to a stroke. The risk of stroke after cervical adjustment is estimated at 1 in 1,000,000, substantially lower than that associated with any medical or other treatment medications or procedures for the same symptoms. To put this in perspective, studies that have assessed the risk from interventions a non-Chiropractor commonly uses for the same complaints have found the following:

Risk of paralysis or stroke from surgeries for neck pain: 15,600 per million
Risk of death from surgeries for neck pain: 6,900 per million Risk of serious gastrointestinal event from non-steroidal anti-inflammatory drugs: 1,000 per million

I understand that while rare, some patients have experienced rib fractures or muscle and ligament sprains or strains following spinal adjustments. I also understand that there have been rare reported cases of disc injuries following cervical and lumbar adjustments although no scientific study has ever demonstrated such injuries are caused or may be caused by chiropractic treatment.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the doctor's office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the doctor's office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care at this office, any outstanding charges for professional services rendered me will be immediately due and payable. I have read and understood the above, and I have had sufficient opportunity to discuss its content with the Doctor of Chiropractic indicated below. I do hereby request and consent to all examinations and care as deemed appropriate by the Doctor of Chiropractic indicated below, for my present condition and for any future conditions for which I may seek care. I also agree to payment for all services rendered.
I consent to treatment
Consent to evaluate and adjust a minor child.*
Being the parent or legal guardian of the minor patient listed above, have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.
I agree
CAPTCHA

Other Species Intake Form

Other Species Intake Form:

Owners name*
Phone*
Email*
Owners birthday

We enter the owners information, like date of birth, into our electronic health records for accurate information. If no date is provided, we use the date of initial service. This information is used when scheduling online for human chiropractic visits.
Owners Address*
Street Address Address Line 2 City State ZIP Code
Animal's name*

Name of the animal or a way to identify
Animal's location*
Animal is located at owner's address

Street Address City State ZIP Code

Where the animal is stabled/resides at.
Species*
Breed*
Color of animal*
Primary job/discipline*
Sex:*
Has this animal been fixed?*
- Yes
- No
- Unsure
Date of Birth*
MM slash DD slash YYYY
Purpose of visit:*
- New Problem/Exacerbation
- Maint/Checkup Observed issues and/or concerns
Time of injury

: Hours

Minutes

AM/PM
What caused the injury
Name of Veterinarian*
First Last
For Chiropractic visits for animals other than equine and canine, the treating vet is required to be present during the treatment.
Veterinarian Phone Number*
Veterinarian Email
Veterinarian Address
Street Address Address Line 2 City State ZIP Code
Surgeries
Medications or supplements
Previous Xrays*
- less than 6 months
- greater than 6 months
- none/NA
Regions for xray
xray findings
Chiropractic Examination and Treatment Consent*
Chiropractic Examination and Treatment Consent Form:

I attest that I am the owner of the animal described in this intake form, or an authorized agent, and being eighteen years or older, do understand, substantiate, and authorize the following:

The purpose of chiropractic services is to promote natural health through the reduction of intervertebral joint restrictions (a lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. The result of this can additionally cause alteration of nerve function and interference to the transmission of nerve impulses, resulting in a lessening of the animal’s innate ability to express its maximum health potential).

Since there are many variables, it is difficult to predict the duration and frequency required for the recommended chiropractic procedures. It’s not uncommon for the response to animal chiropractic to be phenomenal. Most often, there is a more gradual but quite satisfactory response. Rarely, the results are less than expected, although there’s always that potential. 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 (or more commonly, less favorably) to chiropractic care. The fact is, the science of chiropractic and medicine may never be so exact as to provide definitive 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 or the doctor making house/barn calls, gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis, analysis and procedures. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problems. 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 proven to be one of the safest and most effective forms of healthcare available.

Dr. Stephanie B. Parent, D.C., ACCC/AVCA is a Doctor of Chiropractic, licensed in the care of humans and animals through the state of Colorado, and is certified in Animal Chiropractic by the Animal Chiropractic Certification Commission (ACCC) of the American Veterinary Chiropractic Association (AVCA). Additionally, she has received specialized training specific to Animal Chiropractic, and is therefore qualified to perform animal chiropractic services.

Dr. Stephanie B. Parent, D.C., ACCC/AVCA is NOT a veterinarian, and cannot take responsibility for the primary care of my animal. According to Colorado laws for animal chiropractic, the treating veterinarian is required to be present during the treatment for all animals except equid and canine.

Chiropractic care IS NOT intended to replace appropriate veterinary care, but intended to be used concurrently.
I have read and understand the scope of the animal chiropractic care my pet will receive. I understand and acknowledge and agree with the College of Animal Chiropractors description of Animal Chiropractic as follows: “Animal Chiropractic is the examination, diagnosis, and treatment of non-human animals through manipulation and adjustments of specific joints and cranial sutures”. Animal Chiropractic DOES NOT include: dispensing of medications, performing surgery, injecting medications, laser treatments, taping, recommending supplements or replacing traditional veterinary care.

I realize there can be no guarantee as to the nature of my pets condition or the outcome of any procedure, and that the services are to only provide relief from those which are within the scope of animal chiropractic, as defined above.

I hereby authorize Dr. Stephanie B. Parent, D.C., ACCC/AVCA to adjust my animal with Animal Chiropractic. I certify that my animal has had regular veterinary care.
I consent to treatment
CAPTCHA

Intake Forms for all Chiropractic Patients

Please complete one intake for each individual patient

The intake forms below are for all the different types of patients we are able to treat. Each form is loaded into the patient's profile for notes, and records. To enter another intake, please click here after your previous entry has been confirmed.

Equine Intake Form

Equine Intake Form:

Canine Intake Form

Canine Intake Form:

Human Intake Form

Human Intake Form

Other Species Intake Form

Other Species Intake Form:

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