Client Information

Client Information
Owner Name and Surname

First NameLast Name
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile NUmber
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about our service and whom may I thank for this recommendation?
Recommendation
General
I would like to welcome you and your pet to our family. I pride myself on being passionate about the service I offer and strive to give both you and your pet professional, educated and compassionate care. Certain policies are in place to carry out my service as effectively as possible these include:

All animals treated are worked on in consultation with your treating Veterinarian. This may be your usual Veterinarian, or a specialist Veterinarian, or both. If you were not directly referred by your Veterinarian, contact will be made with your Veterinarian before your first session to receive a full medical history as well as permission to treat their patient. All animals will be assessed before physical rehab treatment protocols are decided and carried out.

Patients can only receive treatment if deemed fit enough for rehabilitation by a veterinarian.

Patients suffering from any heart conditions, respiratory conditions or conditions that maybe worsened by exercise must be given approval by your veterinarian to commence therapy
Terms and Conditions
1.   Unfortunately, any animal with infectious or contagious conditions will not be treated, this includes but not limited to kennel cough and canine distemper virus. Please cancel your appointment timeously. I reserve my right, for whatever reason not to treat your pet.
2.   Any appointment cancelled in less than 48 hours or 24 hours will be charged a cancellation fee or the full consultation fee.
3.   If you are late, I may be unable to give your pet a full treatment or in some instances may be unable to treat your pet at all.
4.   Please note that I am a COD practice and kindly request that you settle your bill in cash or EFT within 24 hours of the service/ product purchase. I do not have card facility but do have Snap Scan.
5.   Any refund required for whatever reason will carry a handling fee of 35% of the invoiced amount.
6.   Please do not exercise your pet before our sessions, as well as no feeding your pet 2 hours before & after our appointment.
7.   For your safety, you are not permitted in the laser session for your pet, if you are pregnant or suspect that you are.
8.   Enter my home/ premises at your own risk. I will not be liable for any loss/ injury or theft to you or your pet or your personal belongings/ vehicles etc however occasioned and hereby release any legal or financial liability arising from your visit
9.   I am aware that the practice of holistic treatments is not an exact science and I acknowledge that no guarantees will be made. (Veterinary physiotherapy is a complementary service utilising the skills and knowledge available in our field)
10. If required, please request a copy of my data protection policy and voucher redemption policy.
11.Any photos or videos taken during our session may be used for training or social media.

I am the legal owner of this/ these patients and authorize this complementary therapy for my pet(s) and accept the above-mentioned risks & terms. I assume full financial responsibility for my pets’ therapy. If my account is handed over to Attorneys or other agents for collection, I irrevocably agree to pay interest on the outstanding amount and for all costs related to legal counsel on their agreed scale and collection commission/ terms.
Signature

Medical History
Medical History, Operations, Injuries and Illnesses
Medical History
Veterinary Diagnosis and Reason for referral for Animal Rehabilitation
Medical Diagnosis

Pain and Mobility Scoring

Acute pain (current pain score for the last 3-7 days) Chronic pain (long term pain which continues for 10-14 days and more)
What would you score your pet's pain in the last 7-10 days?
What would you score your pet's pain right now?
How would you describe, how your pet's pain has interfered "generally in their life" over the last 7-10 days?
How would you describe, how your pet's pain has interfered in their "enjoyment of life" over the last 7-10 days?
How would you describe that your pet's pain has interfered in their "ability to lie down" over the last 7-10 days?
How would you describe that your pet's pain has interfered in their "ability to rise from lying" over the last 7-10 days?
How would you describe, how your pet's pain has interfered in their "ability to walk" over the last 7-10 days?
How would you describe, how your pet's pain has interfered in their "ability to run" over the last 7-10 days?
How would you describe, how your pet's pain has interfered in their "ability to climb steps" over the last 7-10 days?
How would you describe, how your pet's pain has interfered in their "ability to play" over the last 7-10 days?
Rate your pet's mood
Rate your pet's vocalisation

Functional Assessment

Owner remarks
Is your pet able to stand still without moving/ changing their foot placement for 60-90 seconds ?
Is your pet able to sit unassisted/ without any help from you?
Is your pet able to transition from sit to stand unassisted/ without any help from you?
Is your pet able to climb steps unassisted/ without any help from you?
Is your pet able to transition from stand to down unassisted/ without any help from you?
Is your pet able to jump on your bed unassisted/ without any help from you?
Is your pet able to jump on your couch unassisted/ without any help from you?
Rate your dog's movement after major activity or heavy exercise
Rate your pet's ease of movement after a long rest
Anything other you would like to add

Reminders

Important Rehab Information
Grooming requirements

1. Cut the fur between the pads of your dogs feet, this help with traction and prevents slipping on tiles and laminate flooring.

2. Trim nails, this also assists with traction and it is very uncomfortable to walk on "high heels" especially during rehab.

Transporation requirements

1. Ensure you have a hammock or safety harness for the drive home from surgery or rehab, something to make your pet feel comfortable.

2. Bring your partner along should you need assistence in making your pet feel less vulnerable with travelling.

3. Hire a crate for use in the car to make the journey safe for your pet if this is an option.

4. Getting into and out of the car can pose a problem too, do you perhaps need a step-up or a ramp or even a "carry" harness? to assist in safe gaurding your back and supporting your pet. remember your pets needs time to become accustomed to these devices.

Home Modifications

1. Barracade steps, to avoid accidents during rehab and post surgery. The use of baby gates works really well.

2. Tiles and Laminate Flooring always pose a threat for slipping and sliding, this should be avoided at all costs during rehab and post-surgery. Consider using yoga mats in high traffic areas. No slipping or sliding during your rehab is a requirement to ensure the plan runs smoothly.

3. Deactivate the doorbell should this cause unnecessary traffic and rushing which may cause an accident with slipping or sliding.

4. Confinement is necessary post surgery and in some cases during conservative rehab, look into rental or purchse of crates or play pens for the safety of your pet.

5. No jumping onto or off beds or couches, the concussive impact on the front legs is a worry but also the possibilty of slipping.

6. Should your pet have other fur siblings at home, ensure they are not playing to rough and that your pet is not knocked over.

Food Stations

1. Raise your pet's food bowl from the floor to ensure a nice neck arch and to alleviate throwing weight forward and encourage weight bearing on the hind limbs. Place a mat under them to provide traction.

Signs of Discomfort to watch out for include (contact your vet)

1. Excessive yawning or panting

2. Changes in personality and behaviour

3. Lethargy

4. Not eating

5. Vocalization

6. Increase in aggression, e.g. biting

7. Showing the white of the eyes (Whale-eyes)

Client Information

Pet Information

Medical History

Pain and Mobility Scoring

Functional Assessment

Reminders

Senior Pet Checklist