New Canine Information

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Steps to See Your Animal:
1. Veterinary Referral/Consent Form (see CollarAndSaddle.com for form) This is a non-negotiable requirement by the State of Texas
2. Fill out the form below.

3. Contact us for an appointment (Text Preferred) 469-430-9898

If you have multiple animals to be seen: Please be sure to include YOUR name on this form, but you do NOT need to re-enter your address and phone number on subsequent forms for each animal.

Canine Fee Schedule: New Patient/New Injury/1+ year since last visit: $80, Existing patient/Follow up visits: $50, Travel Fee ($1.5/mile over 10 miles from Midlothian center), Multi-Animal discount available ($10/additional canine) *

By checking this box, I acknowledge that I understand the current fee schedule outlined above.

I also understand that fees are due at the time of service.

Required

The State of Texas REQUIRES a Doctor of Chiropractic treating animals to have a veterinary referral form on file. This form may be found on our website under the "About Us" section and will need to be signed by both the owner and the veterinarian before securing an appointment. *

I understand the above statement and that I am responsible for obtaining this form.

Required

Client (Owner) Name *

Email Address *

Phone Number *

Address (Please include zip code) *

Animal Name *

Veterinarian Name or Clinic Name (if no specific doctor) *

Veterinarian's Email (if known)

Gender, Intact/Neutered/Spayed *

Breed (list any known) *

Color *

Select Chief Complaint

No Complaint (Wellness)

Stiff

Limping

Dragging

Back Pain

Neck Pain

Tail Pain

Leg Pain

Weak

Bladder Issues

Bowel Issues

Not Eating

Not Jumping

Walk Sideways

Yelps when picked up

No Stairs

No Lifting/Wagging tail

Abnormal Behavior

Other:

Explain Above or List Additional Concerns

When did this (these) issue(s) begin?

This issue came on...

Gradually

Suddenly

Clear selection

Mechanism of Injury (How this issue began)

Unknown

Hard Play

Fell Down Stairs

Woke Up with Pain

Groomers

Past Surgery

History of Trauma/Abuse

Hit by Car

Dog Fight

Agility

Other:

Explain above or list other specific method of injury.

Past Surgeries (excluding spay/neuter)

Current Medications/Supplements

Previous X-rays/Other Imaging Tests/Information

Previous Care

Chiropractic

Massage

HydroTherapy

Other:

Additonal Information you feel may help us help your animal:

Thank You!

We look forward to working with you and your veterinarian to help your animal feel and function their best!

Remaining Steps:
1. Veterinary Referral (see CollarAndSaddle.com for form)
2. Contact us for an appointment (Text Preferred) 469-430-9898

If you are bringing your canine to our brick and mortar office, we are located at 99 Regency Pkwy #111, Mansfield, TX 76063 inside Solutions Alternative Healthcare, LLC. Look for the logo below:

Collar and Saddle Staff

Look for this logo on the door: 99 Regency Pkwy, #111 Mansfield, TX 76063

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms