Referral (Owner Consent)

Veterinary Physiotherapy

Physiotherapy Referral (Owner Form)
Please complete this form prior to any upcoming appointments. If you require a callback or any help booking in please select the option at the end of the form. If you have any questions please email Claire at tailstherapy@outlook.com
I am requesting physiotherapy for*

An acute injury/condition (e.g. ligament rupture)A chronic condition (e.g. osteoarthritis)Maintenence/PerformancePost Operative RehabilitationOther
Owner Name*

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

Street Address

Street Address Line 2

CityCounty

Post Code
Address animal is kept (if different from home address)
Veterinary Practice*
Animal Name *
Animal Type*
Please select*

I would like a call back to discuss my case prior to bookingI already have a bookingI don't yet have a booking but I am happy to book in when I am readyI am unable to book onlineOther
How did you hear about Tails Therapy?

Vet recommendationFriends or FamilySocial MediaGoogleAdvertisementOther
Owner Consent
Photos and videos may be taken during or after your animals treatment. Please confirm if you're happy for these to be shared online by Tails Therapy for marketing purposes.*

I consentI do not consent
Terms & Conditions

● I give consent for my veterinary practice to share the mentioned pets clinical notes with Tails Therapy.

● I give consent for Tails Therapy to discuss treatment and any concerns with my veterinary practice.

● I understand that this referral is valid for 12 months, unless the vet advises differently or the animal receives any musculoskeletal surgery in which case a new referral is required.

● I understand that any new pathologies or lameness require a vet check before further treatment occurs.

● Payment is made at the time of booking and services cancelled within 24 hours of the appointment will incur a £30 fee. Late payments incur a 10% fee of the initial booking cost, further charges will apply for every week the bill is not settled. If payments are late, future consultations may require payment on booking. Tails Therapy reserves the right terminate all future treatment if payment is not made in a timely manner.
Signature

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I agree to the terms and conditions of treatment laid out by Tails Therapy. A full outline can be found at www.tailstherapy.co.uk*

I agreeI disagree
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Veterinary Physiotherapy

Owner Consent