Veterinary Consent for Galen Myotherapy

Veterinary Consent for Galen Myotherapy

Galen Myotherapy is a deep therapeutic massage which treats chronic muscular pain and increase mobility in dogs. Please do call me on 07539 387699 or email me on emma@itsadoggydogworld.co.uk if you have any questions. More information can be found by visiting my website on www.itsadoggydogworld.co.uk. Many thanks Emma Newell. SHOULD YOU REQUIRE THIS FORM SENT TO YOU IN WORD, PLEASE LET ME KNOW.
Date

MonthDayYear
Date
Name of consenting Veterinary Surgeon (M.R.C.V.S)

First NameLast Name
Address of Veterinary Surgery

Address Line 1

Address Line 2

City / town / villageCounty

Post Code
Phone Number

Local Area CodePhone Number
Email address of Veterinary Surgeon
example@example.com
Dogs Name
Breed
Male or female
Medical History appropriate to treating the dog or any relevant comments
Please upload any photos, X rays or additional medical notes that may be relevant when treating this dog.

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Client / Owners Name

First NameLast Name
Client / Owners Address

Address Line 1

Address Line 2

City / Town / Village County

Postal Code
Client / Owner's Number

Local Area CodePhone Number
Client / Owner's email (if known)
example@example.com
I consent to Emma Newell, of It’s a Doggy Dog World Ltd to carryout Galen Myotherapy Treatment which involves deep therapeutic massage, soft tissue manipulation and other massage techniques including Passive Movement Exercises where appropriate for soft tissue and specifically muscular conditions on the above named dog. I understand that by giving consent, I am not responsible for any Myotherapy Treatment and that professional indemnity insurance for this treatment is the responsibility of Emma Newell of It’s a Doggy Dog World Ltd.
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