New Client Form

Please complete the new patient form below so our team can learn about your pet before your visit.
The information you share helps Dr. Kathy Mitchener prepare and ensures we make the most of your time together.

**Medical records, lab results, and referral documents can be uploaded at the end of the form.

Please enable JavaScript in your browser to complete this form.
What type of care is your pet needing?
Name
Address
May we send text messages to this number for scheduling and clinic updates?

Section Divider

Does your pet have insurance ?
Please enter your pets diagnosis or suspected diagnosis. If unsure type N/A
BirthDate (Best Guess)
Click or drag files to this area to upload. You can upload up to 6 files.
Feel free to upload a picture of your pet for their chart.

Section Divider

Payment and Cancellation Policy
Payment 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. No-call/no-show instances will require a deposit for future bookings. To cancel or reschedule, call OR text 901-560-3633 .
Treadmill Session Guidelines
Before Your Session Do not feed your pet within 4 hours of the appointment. Please make sure your pet has urinated and had a bowel movement before arriving. If your pet has not had a bowel movement, tell the treadmill technician before the session starts. If a bowel movement occurs in the tank, a $150 cleaning fee will apply due to draining and sanitation requirements. If your pet has diarrhea, please bathe and brush your dog before the appointment to reduce dirt and loose hair. During Your Session Bring only non crumbly treats. A small amount of peanut butter is ok. Arrival Time Arriving more than 10 minutes late may require rescheduling and may still be subject to the session fee. After Your Session Please dry your dog promptly. If extra drying time is needed, use the back room so the next session can start on time. Thank you for helping us keep the treadmill area clean and running on schedule.
Risk Waiver for Exercise and Acupuncture-Related Injuries
While 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:
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 Instructions

The 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)
I 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 Sedation
I 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
In the unlikely event your pet becomes non-responsive during treatment, do we have your permission to attempt resuscitation (CPR)?
Clear Signature