Treatment Consent Form

Gill Griffiths B.Sc(Hons) MRAC NAVP

Mob; 07949838152 Email ggvetphysio@gmail.com Member of the National Association of Veterinary Physiotherapists
General Patient Information
Owners Name*
Home Address*

CityCounty

Postal Code
Owner E-Mail*
example@example.com
Phone Number
Type of Animal
Age*
Sex*
Name
Insured?

YesNo
If Yes Name of Insurance Co.
Address of Stables if Different from Home

Street Address

Street Address Line 2

CityCounty

Postal Code
Patient History

e.g. medical history, injuries, how long with current owner etc.
Name of Veterinary Surgeon*
Practice Name & Address*

CityCounty

Postal Code
Owners Consent to Physiotherapy Treatment and Privacy Information. Please tick the boxes

I consent to you keeping my contact detailsI consent to you keeping treatment and medical records of the above animal.I consent for the veterinary physiotherapist discussing treatment with my vet and other specialists e.g. saddle fitters, farriersI am happy to receive communications by email.I am happy to receive communications by telephone.I am happy to receive communications by text.No thank you I do not want to receive messages by post.I consent to you taking photographs and videos during treatment for your records
How did you hear about GGVetPhysio?

Word of MouthGoogle SearchFacebookOther
The details you have provided will be held on a secure computer system with no access to third parties and will only be used with regards to treatment of your animal, to contact you regarding treatment of your animal and to confer with the veterinary surgeon or other professionals (e.g. saddle fitters, farriers etc.) in question.

Your details will not be passed on without your consent.

Any time you wish to stop having treatment on your animal(s) or would like your details removed from our system, please contact us with your request.

We regularly review and, where necessary, update our privacy information.
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Gill Griffiths B.Sc(Hons) MRAC NAVP

General Patient Information

Patient History