Sidney Carter, D.C.
702-703-1866 | www.lasvegasanimalchiro.com
Chiropractic Care for Large and Small Animals
* = Required Field
OWNER'S EMAIL ADDRESS*
Which method of communication is best?
GATE CODE (If Applicable)
ANIMAL'S DATE OF BIRTH*
I do not have a veterinarian at this time.My veterinarian's office is out of state.
NAME OF VETERINARY FACILITY
VETERINARY FACILITY ADDRESS / CROSS STREETS / PART OF TOWN
HOW CAN WE HELP? (Please be sure to include when any issues began and how your animal received the injury if applicable.)
HOW DID YOU HEAR ABOUT US?
YES - I understand that Chiropractic Care IS NOT intended to replace traditional veterinary care, but is considered an alternative therapy to be used concurrently and in conjunction with my Veterinarian’s care.
YES - I certify that my animal has had regular, traditional veterinary care, and no limitations, no restrictions or contra-indications for chiropractic care are placed upon the animal. The animal is now being treated by my list Veterinarian.
YES - I understand that Dr. Carter will describe the procedures and explain, to my satisfaction, the purpose for performing them and the risks involved with them. I realize that there can be no guarantee as to the animal’s condition or the outcome of any procedures.
YES - I certify that I will been open and honest with Dr. Carter as to any and all other examinations, diagnostic tests, diagnoses, and treatments for my animal’s condition.
YES - I understand that multiple visits may be necessary to determine the proper course of treatment.
YES - As the owner / guardian of the animal(s) described below, and being eighteen years of age or older, I hereby authorize Dr. Sidney Carter to treat my animal(s).
We will contact you as soon as possible during normal business hours.