New Client Form

Owner's Full Name

Owner's Phone Number

Owner's Email

Address Line 1

Address Line 2

City

Province ProvinceABBCMBNBNLNTNSNUONPEQCSKYT

Postal Code

Country CountryCanadaUSA

Name of Referring Veterinarian

Pet's Name

Species/Breed

Pet's Age

Current Body Weight

Sex Sex Male Female

Spayed/Neutered Spayed/Neutered Yes No

Rabies Vaccination up to date? Rabies Vaccination up to date? Yes No

Allergies

Previous Surgeries

Patient Medical History

Current Medications

History of Presenting Illness

Previous Treatment of Presenting Illness

Owner's Goals

How did you hear about us?

Consent for Treatment Consent for Treatment I agree/consent to participate in animal rehabilitation and physical therapy with Josee Greenacre (RVT/CCRP) I understand that to participate in Animal Rehabilitation/Physical therapy we will require a referral/consent from your veterinarian before starting any treatments. I understand that we will be keeping your veterinarian updated with all treatments and progress. I understand that animal rehabilitation/physical therapy is meant as a complimentary service to regular veterinarian care and NOT as an alternative to veterinary care. I understand that it is a priority to make the patient as well as the client feel comfortable while the treatments are being executed. This being said the safety of every being involved is a necessity and this may include some restrain and muzzling. I understand that I must take full responsibility if any injuries occur to my pet in the event that I deviate from the recommend home treatment regime assigned by Josee’s Animal Wellness Services.