Client Registration

Owner Name*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Contact E-mail Address

Primary Phone Number*

Area CodePhone Number

Primary Phone Number is a Cell Phone*

YesNo

Alternate Phone Number

Area CodePhone Number

Dog's Name*

Breed/type

Gender

MaleFemale

Spayed/Neutered

YesNo

Dog's Age/ Date of Birth

Veterinarian Name/ Clinic Name*

Problem / Vet's Diagnosis

Please briefly describe the problem for which your dog is being seen

When did the problem begin?

Describe how it happened, if known

Please list any medications or supplements your dog is currently taking

Please list any other surgeries, illnesses or medical problems (include dates if known)

Are your dog's immunizations/vaccines current?

YesNo

Thank you for for choosing Dog Rehab Works as the rehabilitation provider for your pet. Please read the following policies:

The client accepts full responsibility and agrees to pay all charges, in full, at the time of service. The client understands that Dog Rehab Works, LLC does not offer payment plans. If the client uses pet insurance, an invoice can be provided for seeking reimbursement. Preapproval is the client's responsiblity. There are NO refunds in the event of denied claims.
Dog Rehab Works, LLC accepts the following forms of payment: Cash, check, credit/debit cards.
The client understands that all returned checks will be charged a $25.00 handling fee. The full amount of any outstanding balance will be due within 15 days from the written notice to prevent a civil action for three times the face amount of the check, but not less than $100.00 and that, in such civil action, the court may award court costs and reasonable attorney's fees.
Dog Rehab Works, LLC offers packages of treatment sessions to facilitate the rehabilitation of your pet. Purchased package sessions must be used within 6 months of their purchase date, othewise Dog Rehab Works reserves the right to terminate the package, and any unused sessions will not be refunded.
Dog Rehab Works, LLC's Appointment Cancellation, No Show & Absence Policy: Consistent participation is important for the success of your animal's rehab program. Cancellations must be made 24 hours in advance of the appointment. Cancellations inside of 24 hours are subject to a $25 charge. Clients are allowed one (1) no-show appointment without charge. Any additional no-shows will result in a $75.00 charge (for those who have purchased a package, a visit will be deducted from the package). Unexplained lapses of more than 4 weeks between sessions, may require a visit to your vet for medical clearance and a reassessment by Dog Rehab Works at an additional $95 charge, prior to resuming rehab. Repeat cancellations or no-shows may be grounds for the termination of rehab care.
Dog Rehab Works, LLC will make every attempt to schedule follow-up visits at the time of service. In the event this doesn't happen, it is ultimately the client's responsibility to contact us to schedule the next appointment.
Dog Rehab Works may use text messaging (SMS) as a means of communicating regarding your pet and appointments. Your registration submission is your consent to Opt In to receiving texts. If you do not wish to receive communication this way, please advise me and you will be Opted Out.

I have read, understand and agree to the above policies and agreements.*

YesNo

Client Registration Form

Medical History

Policies and Agreements