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IPC New Client Form

Client(Required)

Email(Required)

Patient Profile

Name(Required)

Breed(Required)

Weight(Required)

D.O.B.(Required)

Type

Sex(Required)

Male

Female

Neutered

Spayed

Questionnaire

Please be as detailed as possible when answering the questions below!

Owner's Name(Required)

Phone Number(Required)

Owner's Email(Required)

Owner's Address(Required)

Street Address

City

State / Province / Region

ZIP / Postal Code

Emergency Contact Name(Required)

Emergency Phone Number(Required)

How did you hear about Indy Pet CORE?(Required)

Pet's Name(Required)

Breed & Color(Required)

Species(Required)

Dog

Cat

Sex(Required)

Male

Neutered Male

Female

Spayed Female

Pet's Birth Date(Required)

Please provide your primary veterinary clinic's name and phone number

Has your pet had any diagnostic imaging taken at any point in their life (x-rays, MRI, CT scan, etc.)?(Required)

Yes

If yes, please provide clinic name and phone number(Required)

Has your pet been to a specialty veterinary hospital (MedVet, VCAAdvanced, Purdue, IndyVet, etc.)?(Required)

Yes

If yes, please provide hospital name and phone number(Required)

Does your pet get nervous, fearful, reactive (barking, growling, etc.) or uncomfortable with any of the following?(Required)

New people/strangers

Dogs

Touching feet, head, back, legs, etc.

Other

None

Please explain(Required)

Please explain any of the answers to the question above. We want to be prepared and help your pet feel comfortable during their time with us!

Please tell us why you are interested in pursuing rehabilitation therapy for your pet

If lameness or pain is present, when did your pet start showing the associated signs and what locations on the body are affected?

Has your pet had any surgeries?(Required)

Yes

Please provide the date if pursued(Required)

Has your pet been through rehabilitation therapy before?(Required)

Yes

Please provide reasoning why and where this was done(Required)

On a scale of 0 (being none) to 4 (very painful) please rate your pet’s pain level(Required)

0 – No pain

4 – Extreme change in gait, behavior changes, vocalization, etc.

Is your pet currently taking any medications and/or supplements? Please provide the name, strength, and frequency given

Does your pet appropriately use all limbs when walking? Please describe

Please indicate if your pet struggles with the following (check all that apply)

Jumping up (into car, onto bed, etc.)

Jumping down (out of car, off of bed, etc.)

Climbing up (stairs, up a hill, etc.)

Running

Sitting

Laying down

Standing up

None of the above

Do you currently leash walk your pet? How often and how far do you walk? Please describe a typical day for your pet (ex: sleeps most of the day with a 1 mile walk in the evening, very active throughout the day and plays fetch twice daily for 20 minutes each time, etc):

Does your pet know any basic cues/commands? Please list

What goals are you looking to accomplish with your pet in rehabilitation therapy?

Does your pet have any food allergies?(Required)

Yes

Please explain(Required)

Is your pet allowed to have our treats?(Required)

Yes

During therapy, we like to take videos and photos for social media and continuing education. Do you give us permission to use these videos and photos for this purpose?(Required)

Yes

Do you have any questions or concerns that we can address?

We are open Monday and Thursday 8am-5pm, Tuesday 10am-7pm, Wednesday and Friday 8am1pm. Most patients start out with twice a week sessions and then go down to a maintenance frequency if recommended. When are you available to bring your pet to their sessions? You can choose multiple answers and explain in the next question.(Required)

My schedule is flexible and most days/times work

Monday

Tuesday

Wednesday

Thursday

Friday

I have specific availability

Please explain/give specifics on your available times(Required)

Find Us

Make an Appointment

Online Pharmacy

What's Next

1
Call us or schedule an appointment online.
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.

Make an Appointment

Where family pets find loving care

Make an Appointment

317-344-0906

11812 Sylo Crossing,
Zionsville, IN 46077

Home
About Us
Services
Indy Pet CORE
Urgent Care
Online Pharmacy
Contact Us

Monday

8:00am - 6:00pm

Tuesday

8:00am - 6:00pm

Wednesday

8:00am - 6:00pm

Thursday

8:00am - 6:00pm

Friday

8:00am - 8:00pm

Saturday

8:00am - 8:00pm

Sunday

8:00am - 8:00pm

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IPC New Client Form

Patient Profile

Questionnaire

What's Next

Call us or schedule an appointment online.

Meet with a doctor for an initial exam.

Put a plan together for your pet.

Where family pets find loving care