Hydrotherapy & Physical Rehabilitation Form
Ubera Hydrotherapy
A. Client Info
Name of owner :
First Name
Last Name
Email :
example@example.com
Phone number :
Address :
How did you hear about us?
Google
Instagram
Friends / Family
Other
B. Dog
Name :
Gender :
Male
Female
Breed :
Age :
Weight (Kg) :
Spay or Neuter
Spayed (Female)
Neutered (Male)
Vaccinations :
Rabies
Distemper
Bordetella
Parvovirus
Date of last vaccination :
Date of last flea meds :
Allergies :
Vet Referral
A referral can only be made by a pet’s primary care vet, who will provide us with all their necessary medical information we require in order to aid your pet and we will discuss the possible solutions with you when an appointment has been made and all necessary diagnostics and medical history of the pet has been received. Everything we do is driven by our desire to provide the best level of care available in Indonesia today, from our research to our training, to innovation and investment. Working with the Veterinary Professionals in UK, we ensure a more integrated approach to medical care that can be deliver to the pets here in Indonesia.
Primary reason for referral?
Name of clinic :
Name of veterinarian :
Branch location :
Referring veterinarian professional number :
Email address (direct email of veterinarian) :
Contact number :
Veterinarian remarks :
Please evaluate for the condition based on vet evaluation. Check the boxes if any
Orthopedic conditions
Neurologic conditions
Orthopedic conditions patients
Cruciate ligament rupture
Hip / elbow dysplasia
Luxating patella
Osteochondritis
Arthritis
Other
Neurologic conditions patients
Vestibular disease (brain & ears)
Intervertebral disc disease (ivdd)
Degenerative disc disease
Degenerative disease
Spinal cord disease
Idiopathic epilepsy
Epilepsy
Paralysis
Ataxia
Other
Rehabilitation plan based on vet referral
Therapeutic exercise
Electrical stimulation
Neuromuscular reeducation
Passive range of motion
Weight bearing / weight shifts
Joint mobilizations
Hot & cold stimulation
Hydrotherapy
Gait training
Acupressure
Acupuncture
Other
Other medical considerations / cautions? Y/N (Please specific if yes, what type of medication, etc.)
C. Background
Patient history from client
Medical history condition based on the results from client?
Medical history condition based on the results of a veterinarian examination?
Veterinarians & MDT information is required
List of previous & latest medicine history
D. Behavior
Daily routine :
Does your dog have regular workout activities?
Does your dog like going up and down stairs?
Does your dog like to jump?
Does your dog been in K9 training?
Do they have any possessive behaviors (growling / bitting) ?
Any history of aggression?
Is your dog overweight?
How your dog's diet at home?
E. Aims & Goals
What are the goals you’d want to achieve through therapy with Ubera Hydrotherapy & Physical Rehabilitation?
F. Plan
Therapy Plan
Hydrotherapy
Fitness Swim
Physical Rehabilitation
Breed Size
Xs - Small
Medium
Large
X Large
Package
Single Visit
6x Package (For Hydrotherapy Clients)
Appointment (text us for appointment confirmation)
G. Required
Please Upload All Medical History, Image Diagnostics Such As X-Ray, MRI or CT Scan Images
Browse Files
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of
Vet Referral Letter
Browse Files
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of
Vet Complete Diagnosis
Browse Files
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Dog Gait Straight Line Video
Browse Files
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of
Please indicate the following options
Contact us directly for further inquiries
Email us the progress of client
Client Information
We strongly recommend that our therapy is not combined with other therapies, if the patient is currently on vet / mdt's therapy, we suggest that the previous therapy process must be completed before starting the therapy with us. During the therapy process, we are not allow patients to be treated with other methods outside of the methods that we have applied, if something unwanted happens without our knowledge and there is a misdiagnosis, the patient's condition worsens, and other bad circumstances. We take no responsibility for anything beyond our control.
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