Clone of CAPs Fit to Swim Form

CAPs Fit to Swim Form

Pet Medical Information Form for fitness, conditioning, weight loss and recreational swimming and/or underwater treadmill use (non-therapy sessions) TO BE FILLED OUT BY PET'S OWNER
Client Name (owner/agent)*

First NameLast Name
Phone Number - Primary*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Information Section
Name of Patient*
Species*
If other, state species:
Breed:*
Age:*
Sex*
For the safety of our rehab team and other patients, all patients entering the CAPs rehab facility require to be up to date on the following vaccinations.
Is the patient up to date on Rabies vaccination?*
Is the patient up to date on DAP or DAPP vaccination?
Is the patient up to date on Bordetella (Kennel Cough) Vaccination?
For cats, is the patient up to date on Herpes, Calci and Panleukopenia Vaccination?
Reason for hydrotherapy:*
If "Other", selected above, please explain:
Has your pet been examined by a veterinarian within the last year? If you selected "No", an up to date physical exam by a veterinarian is required to use our facility.*
To the best of your knowledge, does your pet have a historyof any of the the following medical conditions?
Heart murmur, known heart disease or other symptoms of heart disease such as fainting or cough
Any history of seizure and/other neurological conditions?
Orthopedic Conditions, arthritis, limping?
History of Orthopedic surgery?
Fecal and/or urinary incontinence?
Acute or chronic ongoing skin conditions?
If yes to any of the above, please briefly explain.
Are there any other health concerns that we should be aware of that you think may influence the pet's ability to swim?
Do we have permission to obtain proof of vaccination and/or a copy of your pet's medical history from your regular veterinarian? If you select "No" we have the right to refuse use of our facility. *
Date*

MonthDayYear
Date
Veterinarian's Name (if known):

First NameLast Name
Regular Veterinary Hospital*
Veterinary Hospital Phone Number:
Please enter a valid phone number.
Contact E-mail (if known):
example@example.com
Town/City and Province*
Signature owner/agent*

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Collingwood Active Pets

come.swim.heal.

2823 Concession 7, Collingwood ON L9Y 3Z1

(Off Poplar Sideroad at the back of Mountain Vista Veterinary Hospital)

Phone: 705 446-0261 Fax: 705 446-1684

e-mail: CAPS@mvvh.ca

www.mountainvistavet.com
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CAPs Fit to Swim Form

Patient Information Section