New Patients: Save Time On Paperwork

We've provided this convenient pre-check in form to save you time filling it out at the clinic, after all filling out paper forms is so last century. You can fill this form out on any device including your smartphone.

Pet owner name

First Name

Last Name

Spouse/Co-owner

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Main number

(###)

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Alternative number

(###)

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Emergency contact

First Name

Last Name

Emergency phone number

(###)

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How did you hear about us?

Pets Information

Pets Name

Pet type

Pet age or Date of birth

Breed (if known)

Color

Sex

Where may we call for Full medical/ lab work and x-rays?

Important clinic infomation

Baseline Animal Rehabilitation Center requires payment in full at time of service or when your pet is discharged from the hospital. We accept cash, check, MasterCard, Visa, American express, Care credit and Discover. A valid Arizona drivers license is required to write a check. There is a $30 NSF (returned check fee).

Submitting this form

By submitting this form, you assume financial responsibility for the pet listed above and agree that your pet will not be released from the hospital until full payment has been received.

Broken Appointment Policy

We value you as our patient and need your cooperation with keeping appointments so that we can provide your care. Missing or late canceling an appointment means we are unable to fill this appointment time with another patient who desperately needs care. Our policy requires: Appointment Confirmation: You must confirm your appointment the business day before. Our practice closes at 5:00pm. It is your responsibility to confirm. This will be considered a missed appointment. • Timely Cancellations: If you need to cancel or reschedule your appointment, you must give us at least 24 hours’ notice. Cancellations made with less than 24hours’ notice will be considered a missed appointment. • On Time Arrivals: If you do not arrive within the first 10 minutes, there will be a $20 late fee. Anything after 10 minutes of the start time of your appointment, you will need to reschedule. This will be considered a missed appointment. • Compliance: Patients are only allowed ONE missed appointment in a 30-day period. After the second missed appointment, you will need to schedule a re-evaluation with Dr. Montes. Many patients use Baseline Animal Rehabilitation Clinic’s services. Your help in keeping your appointments enables us to provide better and timelier care for all our patients.

Photo/Video Release and Liability Waiver

The staff at Baseline Animal Rehabilitation Center (BARC) spends a lot of time with your pet while they’re here for their physical therapy session. We would like to share this time with you by posting pictures and videos on our website, Facebook or other networking and communications venues. However, before we post any pictures or videos of your pet, we’d like your permission. I hereby permit Baseline Animal Rehabilitation Center (BARC) to use pictures and videos taken at BARC, in which my pet/s may appear, for purposes of communications and marketing about Baseline Animal Rehabilitation Center (BARC).

BARC Policies

I would like my pet treated by Baseline Animal Rehabilitation Center. In support of that treatment, I state the following: 1) I am aware that there is a veterinarian on site. My primary veterinarian is aware that I am pursuing physical rehabilitation treatment for my pet and has cleared my pet for such treatment. 2) I acknowledge that the person trained in canine rehabilitation has discussed treatment with me and has advised me of the risks and contraindications associated with the treatment of my pet. I have read these documents given to me by this facility. 3) I have provided the facility with a complete and accurate medical history including details of the current medications/supplements, present injuries, and illnesses of my pet. 4) I understand that physical rehabilitation in small animals is an evolving field and scientific evidence to measure effectiveness is currently limited. 5) I understand the nature and purpose of physical rehabilitation, and fitness programs and such treatment may not accomplish the desired objectives. 6) Any rehabilitation equipment provided by the facility is for the sole purpose of use with my pet and is not for human use. I understand that said equipment is utilized for my pet at my own risk. 7) I understand that in some instances, certain conditions can be exacerbated and worsened by physical rehabilitation. I am aware that there are serious and potentially risks associated with physical rehabilitation modalities and some of the exercise programs. 8) I have been advised of the risks of physical rehabilitation, including but not limited to accidents or injuries. I have read the material entitled benefits and risks of rehabilitation as well as BARC's policy that are on this application. Understanding all the above, I hereby authorize the responsible veterinarian at Baseline Animal Rehabilitation Center and any assistants selected or supervised by them to provide physical rehabilitation treatments for my pet. I expressly agree to hold harmless and release the facility and its employees from any and all responsibility, liability, claims, causes of action, or demands of any nature and cause, including costs. I have read the above and accept these conditions.

Benefits and risks of Physical Rehabilitation

Benefits of Rehabilitation and Hydrotherapy Rehabilitation may include a variety of treatments, including: massage, joint mobilization, range of motion, stretching, therapeutic exercise, balance and proprioceptive training, muscle strengthening, endurance training, sensory re-education, gait retraining, electrical stimulation, therapeutic ultrasound, functional training, heat/cold therapy and hydrotherapy. Physical rehabilitation benefits may: • Increase muscle mass and strength • Improve range of motion and flexibility • Improve overall endurance • Assist with gait training • Improve coordination and balance • Improve neuromuscular function • Improve cardiac and respiratory function • Reduce edema, inflammation and pain • Improve superficial circulation • Assist with weight loss and weight control by increasing metabolism • Accelerate healing and recovery from surgery or injury Risk to dogs of physical rehabilitation. Physical rehabilitation in companion animals is an evolving field, and scientific evidence to measure effectiveness is currently limited. Physical rehabilitation, rehabilitative modalities and hydrotherapy for fitness have associated risks. The risks to your pet vary based on the medical history and condition of your pet as well as the treatment modality that is employed. The following potential risk factors are listed for your pet. Most importantly, despite careful supervision there remains a risk of injury for your pet. Contraindications and precautions for Physical Rehabilitation and Hydrotherapy programs include: • Fever • Cardiac conditions / instability • Abnormal blood pressure (hypotension or hypertension) • Infectious diseases • Contagious skin rashes • Perforated eardrums or severe ear infection • Open wounds • Unstable epilepsy / seizures • Severe asthma or uncontrolled respiratory illness • Pregnancy • Aggression • Water phobia / panic • Unstable fracture repair • Seizures IMPORTANT – The aforementioned list of contraindications is not exhaustive and there may be other conditions identified by your veterinarian that would prevent treatment. This is one reason we require veterinary pre-authorization for any type of physical rehabilitative treatment.

Clients full name (Electronic signature)