Rehabilitation and Under Water Treadmill Referral Form

Please note: Clients who wish to use the underwater treadmill for fitness/conditioning require a signed consent form from their primary veterinarian confirming that the pet is healthy enough to undertake the activity and has no pre-exisiting conditions such as heart disease, respiratory disease, diabetes etc that would require special considerations.

A fully completed referral form is required for all patients referred by the primary veterinarian for rehabilitation services. Please provide all relevant medical notes, xrays, laboratory results etc where applicable.

VETERINARIAN INFORMATION

Reason for Referral *

CLIENT INFORMATION

PATIENT INFORMATION

ASSESSMENT DETAILS

How would you prefer to be contacted with progress reports?*

By submitting this form, you acknowledge that you have examined the above animal and confirm that he/she has no contraindications and to the best of your knowledge is healthy enough to participate in the following activities:

MEDICAL RECORDS

**Patient history must be provided prior to the appointment date**

 

Patient History may include:
1. Medical Records
2. X-rays
3. Lab Results
4. Other Documents

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