This form is exclusively for patients with scheduled appointments.
Se

Initial Consult Submission

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Animal Name

Pets Date of Birth

Sex

Color

Breed

Brief Description of what is wrong with your pet

How did you hear about us?

*I understand that the state of Texas considers acupuncture, chiropractic and laser therapy to be alternative treatments. By clicking this box I agree that my pet can receive alternative therapies.

*I understand the initial consult/exam is $160, which is prepaid and NON REFUNDABLE. Any therapies performed are additional. Acupuncture $90, Chiropractic $65, Laser starts at $60, Shockwave starts at $100. If other treatments are recommended the cost will be discussed at the appointment.

*I understand Back in Motion does not offer general medicine and I need to maintain a relationship with a primary veterinarian.

*I understand there is a $50 fee for cancelling any appointment with less than 48 hours notice.

· I agree to receive text messages from Back In Motion Veterinary Services.

Types of SMS CommunicationsIf you have consented to receive text messages, you may receive messages related to appointments, medical records, or payments.

Standard Messaging Disclosures

· Message and data rates may apply.

· Message Frequency May vary

· You can opt out at any time by texting "STOP."

· For assistance, text "HELP" or visit www.backinmotionvs.com/privacy-policy

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Initial Consult Deposit (Payment Required to confirm booking)

Initial Consult Deposit$160

This form is exclusively for patients with scheduled appointments. Se

Initial Consult Submission

This form is exclusively for patients with scheduled appointments.
Se