Well Adjusted Animals

(858) 232-3463


Animal Intake Form

Animal Intake Form

Katie Manfredi, Doctor of Chiropractic

Patient Health Information

Welcome to our Chiropractic office. Please help us serve you better by completing this patient information sheet as fully as possible. It is our pleasure to serve you!

Personal Information:

Address Line 1
Address Line 2 (optional)

Veterinarian Information:

Health Information:

Terms of Acceptance

When a client/ patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.

Chiropractic has only one goal. It is important that each client/patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.

Vertebral Subluxation: A misalignment of one or more of the vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our only practice objective is to eliminate a major interference to the expression of the body’s innate wisdom. Our method is specific adjusting to correct vertebral subluxations.

I have read and fully understand the above statements. *

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.

I therefore accept chiropractic care on this basis.

Informed Consent for Chiropractic Treatment of your Animal

The California Veterinary Medical Board requires that a veterinarian be present during any musculoskeletal manipulation (MSM) on an animal patient. This is because MSM, when performed upon animal, constitutes the practice of veterinary medicine. The veterinary examination today is to assess if adjustments may be beneficial, that no immediate veterinary medical care is needed and that MSM will not be harmful to the animal patient.

There are potential risks associated with chiropractic treatment including increased pain in the treatment area, minor strain of muscle, tendon, or ligaments, fracture, dislocation, aggravation of previous injury to ligaments, intervertebral discs, nerves or spinal cord. Symptoms of stroke, cerebrovascular injury, inability to walk or ataxia alert patients to seek immediate veterinary care at the closest veterinary hospital.

MSM is considered an alternative (nonstandard) veterinary therapy. There are other treatments for pain including medications, medical care or surgery. You are encouraged to ask questions regarding the possible risks of MSM treatment, and you may use the space below for this purpose.

By entering my name below, it confirms that I have read the paragraphs above and that I understand about possible risks of chiropractic treatment and that I have had the opportunity to ask questions and have my questions answered. Also, I have fully disclosed the complete medical history of my animal regarding the above specified complicating factors and all other conditions that have caused pain for my animal in the past.