{"content":{"sections":[{"name":"Basic Information","questions":[{"name":"Animal First & Last Name","type":"text","required":true},{"name":"Animal Species & Breed","type":"text","required":true},{"name":"Animal Gender & Status","type":"checkboxes","answers":[{"value":"Male"},{"value":"Female"},{"value":"Intact"},{"value":"Desexed"}],"required":true},{"name":"Animal Date of Birth (just the year is acceptable if the full DOB is not known).","type":"text"}]},{"name":"Owner Details","questions":[{"name":"Owner First & Last Name","type":"text","required":true},{"name":"Home Phone Number","type":"text"},{"name":"Mobile Phone Number","type":"text"},{"name":"Email Address","type":"text","required":false},{"name":"Home Address","type":"paragraph","required":true},{"name":"Animal's Address (if different to home address)","type":"paragraph"}]},{"name":"General Questions","questions":[{"name":"Veterinarian (please include the name of the vet centre and if applicable, the vet's name who regularly treats your animal).","type":"text"},{"name":"Has your animal been treated by an animal chiropractor, animal physio or other practitioner besides a vet? (please provide details if yes including who and when the last treatment was).","type":"paragraph"}],"description":"<div>We just need to know a few more things about your animal.</div>"},{"name":"Current Health","questions":[{"name":"What is the main reason for bringing your animal to see us?","type":"radiobuttons","answers":[{"value":"Primary Health Concern"},{"value":"Wellness/Health Check"}],"required":true},{"name":"If primary health concern - Please provide details of the primary health concern/s.","type":"text"}]},{"name":"General Health Information","questions":[{"name":"What is your animal's current lifestyle? (please describe what activities your animal normally does, eg; working/farm/hunting dog, agility dog, family pet, working horse, multiple rider horse/pony, single rider horse/pony etc).","type":"paragraph"},{"name":"Is your animal currently taking any medications or supplements? (if yes, please list these and the reason they are taking each one).","type":"paragraph"},{"name":"Has your animal had any injuries or surgery, do they have any diseases? (if yes, please give as many details as possible).","type":"paragraph"},{"name":"Is there anything else you would like the Animal Chiropractor to know?","type":"paragraph"}],"description":"<div>In order to provide your animal with the best possible care, we need to know some information about their recent general health and well-being. </div>"},{"name":"Consent - Chiropractic Care","questions":[{"name":"I consent to my animal receiving care as recommended by my Chiropractor.","type":"radiobuttons","answers":[{"value":"Yes"},{"value":"No"}],"required":true}],"description":"<div>Chiropractic involves specifically targeted adjustments of the spine to safely restore normal function. This includes unlocking the joints of the spine and limbs that may not be moving as they should. You may hear a popping sound during your animal's adjustments which is the natural noise of the gas being released from a joint being unlocked. Animals may occasionally feel some muscular discomfort following their first adjustments. These symptoms occur as a result of change to the nervous system and the body adapting to those changes. These should settle within 24 hours as the brain perceives the restored normal state of motion.</div>"},{"name":"Consent - Clinical Information","questions":[{"name":"I give consent for my animal's clinical information to be shared with my veterinarian and or another registered health provider where appropriate.","type":"radiobuttons","answers":[{"value":"Yes"},{"value":"No"}],"required":true},{"name":"I give consent for Two Hands Health Ltd to request my animal's clinical information, previous notes and X-rays from my previous Chiropractor or other health care provider where appropriate.","type":"radiobuttons","answers":[{"value":"Yes"},{"value":"No"}],"required":true}],"description":"<div>As you may have been referred to us by your veterinarian or other health care provider, it is standard practice to request your previous notes and X-rays where appropriate from your animal health care providers. It is also standard practice for us to share your animals clinical information with your veterinarian and or another registered health provider where appropriate. </div>"},{"name":"Consent - Digital Data Storage","questions":[{"name":"I give consent for Two Hands Health LTD to store and manage my clinical and personal information digitally.","type":"radiobuttons","answers":[{"value":"Yes"},{"value":"No"}],"required":true}],"description":"<div>Two Hands Health LTD is a modern health practice and as such we use digital technology for the storage and management of patient data including but not limited to; contact information and clinical records. We use Cliniko, (www.cliniko.com) an online Patient Management System to store and manage your data. We also use email services from Google Inc to communicate with you, as such your contact data (name, email address) shared on this form is stored in the Google Inc GSuite services. Please see our privacy policy for further information. </div>"},{"name":"Signature","questions":[{"name":"Signature","type":"signature","required":true}],"description":"<div>Please sign below to confirm your consent as indicated in your selections above (use finger or mouse).</div>"},{"name":"Thank you!","questions":[{"name":"How did you hear about Two Hands Health?","type":"checkboxes","answers":[{"value":"Friend/Family"},{"value":"Facebook/Social Media"},{"value":"Animal Health Care Professional"},{"value":"Newspaper/Newsletter"},{"value":"Leaflet/Business Card from a local business"},{"value":"Google"}]}]}]},"name":"Animal New Patient Form","restricted_to_practitioner":false}