NHPPRC- New Client Form

New Client Form

288 Lowell Road Hudson NH 03051
**PLEASE NOTE: We are taking new patients, but we are currently booking out a few weeks for consults in order to be able to facilitate the best patient care! Please allow 3-5 days to be contacted about an appointment! We are getting patients in as soon as we can!**
Date*

MonthDayYear
Date
Pet Information: Name*
Age
Breed
Color
Male/Female
Spayed/Neutered/Intact
Preferred Contact Method: (check all that apply)

Text MessageEmailPhone Call
Client Name*
FIRST LAST
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number: CELL*
Secondary Phone Number
E-mail address*
example@example.com
Spouse/Other

First NameLast Name
Spouse/Other Phone Number
Please enter a valid phone number.
What is your pets current diagnosis? *
Write "unknown" if no diagnosis or unsure
What is the reason for seeking rehabilitation for your pet? (check all that apply)

Post-surgeryPre-surgeryArthritisOverweightOther
Referring surgeon/doctor/hospital*
General Practitioner Doctor/Hospital (if different from above)*
List 'N/A" if same as above
Species*

CanineFeline
Breed*
Age*
Sex*

Female - IntactFemale - SpayedMale - IntactMale - Neutered
Color/Markings*
Duration of current diagnosis/concern, and areas affected*
Surgery and/or Injury Date*
Any other medical history we should be aware of?*
Write "N/A" if none
Current Medications *
Current Supplements (Please include joint supplements, vitamins, fish oils, etc.)*
Current heartworm preventative, flea/tick preventative*
Current Level of activity- please include any restrictions*
CURRENT level of activity*

Sedentary - out to eliminate onlyLight walks (1-3 times per day for under 10 minutes)Moderate (1-3 times per day for 10-30 minutes)Heavy (1-3+ times per day for 30 or more minutes)Other
PREVIOUS level of activity*

Sedentary - out to eliminate onlyLight walks (1-3 times per day for under 10 minutes)Moderate (1-3 times per day for 10-30 minutes)Heavy (1-3+ times per day for 30 or more minutes)Other
Previous level of activity*

Sedentary - out to eliminate onlyLight walks (2-3 times per week for under 20 minutes)Moderate (4-5 times per week for 20-40 minutes)Heavy (5-7 times per week for 30 or more minutes)Other
Activities Requiring Assistance:*

NoneWalkingGetting upGetting into carUrination/defecation positioningOther
Has your pet had any previous rehabilitation therapies?*
Home Flooring- select any where your pet spends majority of their time*

HardwoodTileCarpetLinoleumArea rugsOther
Do you have stairs? If yes, how many does your pet normally need to use?*
Do you have other pets in the home? If yes, how many and ages?
Pets Current Diet (Please list the Brand, Measured Amount, Frequency) *
Favorite Types of Treats *
Favorite Types of Treats (select all that apply)

TREAT?!?! Did someone say TREAT?!?! Hooray!Peanut ButterCheeseFreeze Dried Protein Treats (Beef, Liver, Chicken)Chewy/Soft TreatsCrunchy treatsOther
Any dietary restrictions? (We utilize lots of treats for positive reinforcement!)*

YesNo
Any dietary restrictions? (We utilize lots of treats for positive reinforcement!)
Current Appetite*

NormalIncreasedDecreased
Any Vomiting?*

YesNo
Any Diarrhea?*

YesNo
Does your pet have full control of his/her bowels?*

YesNo
Does your pet have full control of his/her bladder?*

YesNo
Does your pet have Pet Insurance?
Do you have any concerns/restrictions performing exercises with your pet at home?
Rehabilitation Preference: Please check all that apply*

Any modalities recommendedHydrotherapyRehabilitation (Floor Exercises)AcupuntureMassageOther
Family expectations for pet - please select all that apply:*

Pain free/Pain ControlAble to eliminate without assistanceShort walksLong walksHome activities - stairs, jump on and off furniture, active in the yard, etc.Weekend activities - i.e. beach hiking camping swimmingReturn to full functionOther
Please provide any other important information not included above:*
Multimedia Release: NH Pet Physical Rehabilitation Center often records photographs and videos of patients while at the clinic for the purposes of education, promotion, or advertising. Please select one of the following options:*

I authorize the use of my pet’s image or likeness for these purposes.I do not authorize the use of my pet’s image or likeness for these purposes.
Please attach any discharge instructions or medical history here. Please ask your veterinarian and/or surgeon to email pertinent records and history to info@nhpetrehab.com

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Signature*

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Date*

MonthDayYear
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New Client Form

**PLEASE NOTE: We are taking new patients, but we are currently booking out a few weeks for consults in order to be able to facilitate the best patient care! Please allow 3-5 days to be contacted about an appointment! We are getting patients in as soon as we can!**

PLEASE NOTE: We are taking new patients, but we are currently booking out a few weeks for consults in order to be able to facilitate the best patient care! Please allow 3-5 days to be contacted about an appointment! We are getting patients in as soon as we can!