New Client Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 2Name: *FirstLastAddress: *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Mobile Phone : *Referring Vet :Pets Name: *Sex *MaleFemaleMale NeuteredFemale Spayed Photo Description) Breed *Mixed BreedFelineAffenpinscherAfghan HoundAiredale TerrierAkitaAlaskan MalamuteAmerican BulldogAmerican English CoonhoundAmerican Eskimo DogAmerican FoxhoundAmerican Hairless TerrierAmerican Staffordshire TerrierAmerican Water SpanielAnatolian Shepherd DogAustralian Cattle DogAustralian ShepherdAustralian TerrierAzawakhBarbetBasenjiBasset HoundBeagleBearded CollieBeauceronBedlington TerrierBelgian LaekenoisBelgian MalinoisBelgian SheepdogBelgian TervurenBergamasco SheepdogBerger PicardBernese Mountain DogBichon FriseBlack and Tan CoonhoundBlack Russian TerrierBloodhoundBluetick CoonhoundBoerboelBorder CollieBorder TerrierBorzoiBoston TerrierBouvier des FlandresBoxerBoykin SpanielBracco ItalianoBriardBrittanyBrussels GriffonBull TerrierBulldogBullmastiffCairn TerrierCanaan DogCane CorsoCardigan Welsh CorgiCarolina DogCatahoula Leopard DogCavalier King Charles SpanielCentral Asian Shepherd DogCesky TerrierChesapeake Bay RetrieverChihuahuaChinese CrestedChinese Shar-PeiChinookChow ChowCirneco dell’EtnaClumber SpanielCocker SpanielCollieCoonhoundCorgiCoton de TulearCurly-Coated RetrieverDachshundDalmatianDandie Dinmont TerrierDanish-Swedish FarmdogDeutscher PinscherDoberman PinscherDogo ArgentinoDogue de BordeauxDutch ShepherdEnglish BulldogEnglish Cocker SpanielEnglish FoxhoundEnglish SetterEnglish Springer SpanielEnglish Toy SpanielEntlebucher Mountain DogEskimo DogEstrela Mountain DogField SpanielFinnish LapphundFinnish SpitzFlat-Coated RetrieverFox TerrierFrench BulldogGerman Longhaired PointerGerman PinscherGerman Shepherd DogGerman Shorthaired PointerGerman Wirehaired PointerGiant SchnauzerGlen of Imaal TerrierGolden RetrieverGordon SetterGrand Basset Griffon VendéenGreat DaneGreat PyreneesGreater Swiss Mountain DogGreyhoundHarrierHavaneseIrish Red and White SetterIrish SetterIrish TerrierIrish Water SpanielIrish WolfhoundItalian GreyhoundJapanese ChinJapanese SpitzKeeshondKerry Blue TerrierKomondorKooikerhondjeKuvaszLabrador RetrieverLagotto RomagnoloLakeland TerrierLancashire HeelerLeonbergerLhasa ApsoLowchenMalteseManchester TerrierMastiffMiniature American ShepherdMiniature Bull TerrierMiniature PinscherMiniature SchnauzerNeapolitan MastiffNewfoundlandNorfolk TerrierNorwegian BuhundNorwegian ElkhoundNorwegian LundehundNorwich TerrierNova Scotia Duck Tolling RetrieverOld English SheepdogOtterhoundPapillonParson Russell TerrierPekingesePembroke Welsh CorgiPetit Basset Griffon VendéenPharaoh HoundPlott HoundPointerPolish Lowland SheepdogPomeranianPoodle (Standard, Miniature, Toy)Portuguese PodengoPortuguese Water DogPresa CanarioPugPuliPumiPyrenean MastiffPyrenean ShepherdRat TerrierRedbone CoonhoundRhodesian RidgebackRottweilerRussell TerrierRussian ToySaint BernardSalukiSamoyedSchipperkeScottish DeerhoundScottish TerrierSealyham TerrierShetland SheepdogShiba InuShih TzuSiberian HuskySilky TerrierSkye TerrierSloughiSmall Munsterlander PointerSoft Coated Wheaten TerrierSpanish Water DogSpinone ItalianoStaffordshire Bull TerrierStandard SchnauzerSussex SpanielSwedish VallhundThai RidgebackTibetan MastiffTibetan SpanielTibetan TerrierToy Fox TerrierTreeing Walker CoonhoundVizslaWeimaranerWelsh Springer SpanielWelsh TerrierWest Highland White TerrierWhippetWire Fox TerrierWirehaired Pointing GriffonWirehaired VizslaXoloitzcuintliYorkshire TerrierReason for visit(Brief Description) BirthDate (Best Guess) *Medications or Injections your pet is currently taking. *Pet Records/X-Rays Click or drag a file to this area to upload. Feel free to upload a picture of your pet for their chart. NextPayment and Cancellation PolicyI have read this policyPayment Policy Please plan to pay for services at the time they are provided. We accept all major forms of payment. Cancellation Policy A minimum of 24 hours’ notice is required to cancel or reschedule an appointment. Late cancellations or missed appointments will incur a $75 fee. Repeated no-call/no-show instances may require a deposit for future bookings. To cancel or reschedule, call OR text 901-687-4334 or reply to your appointment reminder text. Treadmill Session Guidelines I have read the above guidelinesBefore the Session: Do not feed your pet within four hours of the Ensure your pet has urinated and had a bowel movement before If no bowel movement has occurred, inform the treadmill technician prior to the session. A $150 fee will be applied if a bowel movement occurs in the tank, as this requires draining and cleaning. If your pet has diarrhea, please Brush and bathe your dog prior to the session to minimize dirt and hair During the Session: Use only non-crumbly treats; minimal amounts of peanut butter are acceptable if Arrive on Being more than 10 minutes late may result in rescheduling and may incur the session fee. After the Session: Dry your dog promptly and use the back room for extended drying to allow the next session to proceed as scheduled. Thank you for your cooperation in helping us maintain a clean and efficient environment for all our clients and their pets!Risk Waiver for Exercise and Acupuncture-Related InjuriesI have read the above guidelinesWhile we take every precaution to ensure your pet’s safety during underwater treadmill sessions and acupuncture treatments, any physical exercise—especially for elderly dogs or dogs prone to genetic disorders—carries a risk of injury. Similarly, acupuncture, while generally safe and beneficial, may occasionally lead to side effects such as mild bruising, soreness, or discomfort. Injuries or reactions outside our control can sometimes occur. If you notice any unusual behavior, discomfort, or symptoms in your pet following a session or treatment, we recommend contacting your regular veterinarian or an animal hospital immediately. By signing this agreement, you acknowledge and accept these risks. Treatment Consent I, the undersigned, certify that I am the legal owner or authorized agent of the abovementioned pet and have the authority to make medical and treatment-related decisions on their behalf. I authorize Angel Care Natural Healing & Acupuncture for Pets and its staff to provide necessary rehabilitative care, treatments, and therapies as deemed appropriate by the attending veterinarian. I understand that rehabilitative therapies, including but not limited to hydrotherapy, laser therapy, acupuncture, massage, and other related modalities, are not without risk and may involve potential complications. The benefits and risks of the proposed treatments have been explained to me, and I have been given the opportunity to ask questions. Photo & Social Media Waiver: *YesNo You grant Angel Care permission to photograph or video your pet during sessions for use in social media, educational materials, and promotional content. To OPT out please check no. Consent InstructionsThe following description clarifies your options for consent. Pick the form that applies to your pet's treatment. Complete both forms only if your pet will receive both types of treatment. One form covers rehabilitation services. The other covers chemotherapy and sedation. Review the descriptions before signing. Ask questions if any details are unclear.General Consent for Treatment – Rehabilitation & Acupuncture (Complete this form if your pet is receiving rehabilitation services such as water treadmill, laser or acupuncture)NOYESI authorize Angel Care Natural Healing and Acupuncture for Pets to treat my pet with chemotherapy and/or sedation if deemed necessary and discussed during the appointment. I understand the potential risks and side effects associated with chemotherapy and sedation. I have had the opportunity to ask questions, and I am satisfied with the information provided. I agree to hold Angel Care Natural Healing and Acupuncture for Pets, its veterinarians, staff, and affiliates harmless for any adverse reactions or unexpected outcomes that may occur, provided that reasonable care and skill are exercised.Consent for Chemotherapy and SedationNOYESI authorize Angel Care Natural Healing and Acupuncture for Pets to treat my pet with chemotherapy and/or sedation if deemed necessary and discussed during the appointment. I understand the potential risks and side effects associated with chemotherapy and sedation. I have had the opportunity to ask questions, and I am satisfied with the information provided. I agree to hold Angel Care Natural Healing and Acupuncture for Pets, its veterinarians, staff, and affiliates harmless for any adverse reactions or unexpected outcomes that may occur, provided that reasonable care and skill are exercised.Emergency Care Authorization *Yes, attempt resuscitationNo, do not attempt resuscitationIn the unlikely event your pet becomes non-responsive during treatment, do we have your permission to attempt resuscitation (CPR)?Signature * Clear Signature PreviousSubmit