Physical Rehabilitation Waiver and Policies Form Physical Rehabilitation Waiver and Policies Name * Name First First Last Last Phone * Email * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Emergency Contact * Emergency Phone * Financial Policy: Payment is due at the time of service (or booking of packages) and can be given in the forms of cash, check, card (Visa, Mastercard, Discover, Amex) or CareCredit. You understand that you are responsible for the charges. * I understand this policy Cancellation, Missed appointments, late arrival policy: Pawsitive Integrative Veterinary Care does everything they can to stay on schedule and make it fair for each pet to get their amount of time needed for their rehabilitation sessions so we can live up to our standard of care. Due to this if you are more than 5 minutes late to your appointment you will be asked to reschedule. * I understand this policy Pawsitive Integrative Veterinary Care has a No Show/Cancellation Policy that is as follows - We require 24 hours' notice for any cancelled appointments. The first time this happens we will not assess any charges. Any additional missed/no show appointments or cancellations without proper notice are subject to a $70 charge. Please acknowledge that you have read and understand this policy * I understand this policy Underwater Treadmill Policy: Please be sure your pet has urinated and defecated before your scheduled underwater treadmill appointment. We understand accidents happen; therefore, the first occurrence is at no charge. However, the SECOND OCCURRENCE does have a water changing fee of $50 If additional occurrences happen, we reserve the right to charge water changing fees OR discontinue use of treadmill as we see fit. * I understand this policy Medical Release: If an emergency were to occur while your pet was at their session with PIVC and immediate intervention is necessary one of the veterinarians at Lincolnway Veterinary Clinic can oversee medical treatment. Please initial that you understand and authorize emergency treatment should the need arise. * I understand this policy Image/Video release: We will often take pictures or record videos of patients to be used for educational or marketing purposes. * I authorize the use of my pet’s images or likeness for these purposes I DO NOT authorize the use of my pet’s images or likeness for these purposes Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.
