Owner Consent Veterinary Physiotherapy Referral

Physiotherapy Owner Consent Form

Please use this form to request physiotherapy/ rehabilitation for your animal
I am requesting physiotherapy for: *
Pick the most appropriate
Owner/ Guardian's Details
Name*

First NameLast Name
Contact Number*
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

Town/ CityState / Province

Postal Code
Veterinarian Details
Veterinarian Name

First NameLast Name
Veterinary Practice*
Email
example@example.com
Has your vet seen your animal for this issue?

Yes and received treatmentNoNot seen vet in last 6 months
Animal's Details
Name
Animal Species
Location animal is kept if different from home address.

Street Address

Street Address Line 2

Town/ CityState / Province

Postal Code
What3Words
If your animal is kept at a location which isn't easy to find or doesn't have a postcode on google maps, please search the entrance using What3Words to give a unique 3 letter code. e.g. paced.minute.escape
Temperament
Please briefly tell us about the current issue/ reason for physiotherapy
Preferred Method of Contact*

PhoneEmail
Photos and videos may be taken during or after your animal's treatment. Please confirm if you're happy for these to be used by Animal Rehab Partners for marketing purposes (this may include, website, newsletters, social media)

I agreeI disagree
I would like to join the client newsletter mail-list and understand I can opt out at any time. This will not affect the receipt of appointment reminders.

I agreeI disagree
By completing this form you agree to Animal Rehab Partners' terms and conditions:

● I give consent for my veterinary practice to share the above mentioned animal's clinical notes with Animal Rehab Partners.

● I give consent for Animal Rehab Partners to discuss treatment and any concerns with my veterinary practice.

● I understand any new pathologies or lameness require a vet check before further physiotherapy/ rehabilitation treatment can occur.

● Payment is required by/on the day of the appointment and services cancelled within 24 hours of the appointment will incur a late cancellation fee.

For full terms & conditions please visit www.animalrehabpartners.co.uk/Terms&Conditions
Date completed

MonthDayYear
Date
Should be Empty:

Physiotherapy Owner Consent Form

Owner/ Guardian's Details

Veterinarian Details

Animal's Details