Pre-Surgical Consult Form
Full Name
*
First Name
Last Name
Phone Number
*
E-mail
example@example.com
Pet Info
Name
Age
Species
Breed
Sex
Diet
Please list your pet's current medications and supplements, including dose and frequency if possible:
Describe your pets environment - Stairs? Flooring? Other pets? etc:
Describe your pets regular activity and daily routine:
Describe your current concerns regarding your pet's mobility - Previous surgeries/diagnoses, etc:
Are you interested in pursuing post-operative rehabilitation with your pet?
Yes
No
Not Sure
If yes, please describe your goals for rehabilitation:
Any specific questions or concerns you would like our rehab specialist to discuss?
Are you interested in a Help 'Em Up Harness?
Yes
No
Not Sure
Accident and Injury Liability Disclaimer
I understand that the staff at Blue Springs Animal Rehabilitation Centre will take any and all necessary and reasonable precautions to ensure the safety of my pet. I understand, however, that should my pet sustain an injury while participating in any and all physical activities offered at the center, Blue Springs Animal Rehabilitation Center will not be held responsible for any veterinary assessment or treatment.If my pet has been referred to Blue Springs Animal Rehabilitation Center by my veterinarian for a diagnosed health concern, I understand that treatment recommendations and protocols will be developed for this particular condition. Should the referring veterinarian’s diagnosis be incorrect, Blue Springs Animal Rehabilitation Center will not be held responsible for any unexpected results arising from the recommended activities. I understand that if my pet is not responding to treatment as expected, I may be asked to return to my veterinarian for reassessment or further investigation.
Name
First Name
Last Name
Signature
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