TheraPaws Rehabilitation and Therapy Veterinary Consent Form
917 W Foothill Blvd, Upland, CA 91786 (909)202-7582 www.TheraPaws.Pet
Date
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Month
-
Day
Year
Date
Pet's Name
First Name
Last Name
Pet Owner's Name
First Name
Last Name
Consenting Veterinarian Information
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Best method and time to contact you
Patient Pertinent Medical History (diagnosis and brief description):
Pertinent Diagnostic Tests and Results
Current Medication(s)/Supplement(s):
Please list any other Special Recommendations/Comments/Restrictions:
Is your patient up-to-date on vaccinations including rabies?
yes
no
not sure
Please check all that apply:
The above stated patient is to receive physical rehabilitation therapy by Jami Waldrop RVT, CCRP, CERP. (indirect veterinarian supervision required)
The above stated patient is to take part in a massage, exercise, and/or fitness program. Any concerns or precautions needed to be taken in the designing of the therapeutic exercise and massage plan are listed on this form.(veterinary supervision not required)
The above stated patient is to receive a weight loss program. (veterinary indirect supervision only required for clinical patients)
The above patient is recommended for the senior enrichment program (veterinary supervision not required)
Signature: by signing this document, the above stated veterinarian acknowledges a veterinarian-client-patient-relationship with the above stated patient and assumes indirect supervision when applicable.
Submit
As of January 1,2022, California Code of Regulations: 2038.5 regarding Animal Physical Therapy (APR) states that registered veterinary technicians (R.V.T.s) may perform APR under the degree of direct or indirect supervision determined by the veterinarian who has established the veterinarian-client-patient relationship.
Should be Empty: