New Client Form

Acupuncture

Chiropractic / VSMT

Underwater Treadmill/Hydrotherapy

Therapeutic Exercise

Land Treadmill

Cart Fitting/Adjustments

Massage Therapy

Laser Therapy

If there is anything that you believe your pet is doing at home (such as walking differently, etc.) of which you believe would be helpful for us to view a video clip, please feel free to provide one! This is particularly helpful with shy/fearful pets who may not be willing to exhibit their "normal" behavior in the examination.

Videos should be sent to info@IVRSM.com

Subject line of your email should be your pet's first and last name, as well as the date/time of your appointment.

We look forward to meeting you and your pet!!!
-IVRSM Staff

New Client Form

Welcome to Integrative Veterinary Rehabilitation and Sports Medicine! Would you please take a moment to provide us with the following information for your pets initial evaluation with us? Doing so will help us better serve you and your pet. Thank You!

Client Information

* Indicates required field

Name *

First

Last

Home Phone *

Cell Phone *

Work Phone *

Spouse/Partner Name *

First

Last

Spouse/Partner Cell Phone *

Best way to contact you? *

Address (including City, State and Zip Code) *

Email *

How did you hear about IVRSM? *

Doctor Preference *

Patient Information

Pet's Name *

Birthdate *

Species *

Breed *

Sex *

Color *

Weight *

Primary Care Animal Hospital *

Primary Care Veterinarian *

Primary Care Hospital Phone Number *

Primary Care Hospital Email *

Has your pet been seen by any other veterinarians for this problem? If so, please list practice name and veterinarian below. *

Has your pet had any diagnostic imaging done for this problem? *

If diagnostic imaging was done, please tell us where. *

Please be sure that we have received your pet's medical records from your primary care veterinarian. We need to have these to combine with our physical examination findings to enable us to develop the most accurate diagnosis and formulate the finest therapeutic plan for your pet. (Some hospitals will not release a pet's medical record without the owner/pet parents consent.)

Questionnaire for Initial Evaluation Appointment

What are your primary reason(s) and goal(s) for coming to IVRSM? *

What does your pet eat? (Please indicate kind(s) and form(s) of food, such as brand, primary protein source (chicken, fish, beef, etc) kibble, canned, etc; amount of food, including treats) *

Does your pet currently require assistance for normal activities? (Walking, getting up, getting into car, positioning for urination and/or defication, etc) Please explain as much as possible. *

What is your pet's current activity? (Frequency and length of walks, etc) *

What changes have you noticed in your pet's activity level? *

What type of flooring do you have in your home? *

Is your pet slipping or having trouble getting up on slick surfaces such as hardwood/tile? *

Are there any stairs your pet must maneuver daily and, if so, do they have any difficulty? *

What supplements does your pet currently receive (such as joint supplements, vitamins, fish oils, etc. Please include brands, amounts, etc)? *

What medications does your pet receive (including all prescribed and routine medications such as heartworm preventative, flea/tick preventative, etc. Please include brand and dose)? *

Are there any time constraints that we should be aware of for the future in working with your pet? *

Submit Form

Acupuncture

Chiropractic / VSMT

Underwater Treadmill/Hydrotherapy

Therapeutic Exercise

Land Treadmill

Cart Fitting/Adjustments

Massage Therapy

Laser Therapy

New Client Form

Welcome to Integrative Veterinary Rehabilitation and Sports Medicine! Would you please take a moment to provide us with the following information for your pets initial evaluation with us? Doing so will help us better serve you and your pet. Thank You!

Client Information

Patient Information

Questionnaire for Initial Evaluation Appointment

Location

Integrative Veterinary Rehabilitation and Sports Medicine
(located in Hanover Park Animal Care Center)
1920 Ontarioville Road
Hanover Park, Il, 60133
P: 630.540.2660
F: 630.477.0292

Contact Us

Acupuncture

Chiropractic / VSMT

Underwater Treadmill/Hydrotherapy

Therapeutic Exercise

Land Treadmill

Cart Fitting/Adjustments

Massage Therapy

Laser Therapy

New Client Form

Welcome to Integrative Veterinary Rehabilitation and Sports Medicine! Would you please take a moment to provide us with the following information for your pets initial evaluation with us? Doing so will help us better serve you and your pet. Thank You!

Client Information

Patient Information

Questionnaire for Initial Evaluation Appointment

Location

Integrative Veterinary Rehabilitation and Sports Medicine(located in Hanover Park Animal Care Center)1920 Ontarioville RoadHanover Park, Il, 60133P: 630.540.2660F: 630.477.0292​

Contact Us

Integrative Veterinary Rehabilitation and Sports Medicine
(located in Hanover Park Animal Care Center)
1920 Ontarioville Road
Hanover Park, Il, 60133
P: 630.540.2660
F: 630.477.0292