Veterinary Consent

VETERINARY CONSENT FORM FOR CANINE HYDROTHERAPY TREATMENT

One of your clients has enquired about hydrotherapy for their dog. Please confirm that you agree to such treatments for this dog by completing and returning this form to us. Please also take into consideration the contraindications to hydrotherapy listed below. Thanking you in advance.

OWNER'S NAME:                                                                   NAME OF DOG:

ADDRESS:

TEL:

BREED OF DOG:

AGE OF DOG:

DOG / BITCH:                                       NEUTERED / ENTIRE:

DATE OF LAST VACCINATION:

INJURY / CONDITION / TYPE OF SURGERY:

OTHER COMMENTS - PLEASE INCLUDE BEHAVIORAL ISSUES/MEDICATION:

Contraindications to Hydrotherapy include: Open Wounds, Surface Infections, Contagious Diseases, Cardiac & Respiratory Dysfunctions, Severe Peripheral Vascular Disease, Epilepsy (one or more fits in the week preceding Hydrotherapy), Water Phobia causing extreme panic reactions and Vestibular Syndrome.

NAME OF VETERINARY CENTRE:

SIGNATURE OF VET:

PLEASE PRINT:

DATE: