VETERINARY ASSESSMENT AND REFERRAL FORM FOR SUITABILITY TO
HYDROTHERAPY AND PHYSIOTHERAPY
ANIMAL DETAILS
Name……………………………. Breed…………………………….
Colour………………............
Sex…………….
Insured
Date of Birth…………………
Yes/No
Policy No…………………….Insurance Company……………………………… Expiry Date………………….
OWNER’S DETAILS
Name…………………………………………………………………………………………………………………….
Address…………………………………………………………………………………………………………………
…………………………………………………………………………………Post Code…………………………
Home Telephone Number…………………………………….Mobile………………………………………………
Email Address……………………………………………………………………………………………………………
I/we declare that I/we am/are the legal owner(s) of the dog named above and that the information supplied on this
form is correct. I/we have read and fully accept the terms and conditions printed overleaf.
I/we authorise the release of the veterinary history of the above name dog to Chesterfield Hydrotherapy Referral
Centre.
SIGNATURE(S)…………………………………………………………………………………………………………DATE……………………………..
PRACTICE DETAILS
Practice Name…………………………………………………………………………………………………………
Practice Address…………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………..
Telephone Number………………………Fax Number……………………Email Address…………………………
Referring Veterinary Surgeon………………………………………………………………………………………
Condition Referred For………………………………………………..Medications…………………………………
Areas of Concern or Caution…………………………………………………………………………………………
Vaccinated
Yes/No
Vaccine Expiry Date………………….
In your opinion is the dog named above in a suitable state of health to undergo hydrotherapy
treatment YES / NO
I give my consent for the above named animal to receive veterinary physiotherapy treatment and/or
remedial exercise as deemed necessary by Lindsey Fidler PgD Vet Phys, MNAVP YES/NO
Signature…………………………………………………………Date………………………..
Document1
16/04/2014
TERMS AND CONDITIONS
Please read carefully
1.
Whilst every care is taken of the dogs undergoing treatment and in the maintenance of the water and equipment,
all dogs receive hydrotherapy treatment entirely at their owner’s risk.
2.
All treatment courses, including those to be part of an insurance claim, must be paid for in advance. Individual
sessions must be paid for on the day of treatment.
3.
If you need to cancel or change your appointment we require a minimum of 24 hours notice otherwise you will
have to pay for your missed session.
4.
Dogs cannot be treated without the prior authorisation of their Veterinary Surgeon.
5.
Dogs with infectious or contagious conditions OR who have been in contact with infectious or contagious
diseases, such as PARVOVIRUS,ear, eye, skin infections, gastric upset, kennel cough etc will not be treated.
Owners are advised to cancel appointments with at least 24 hours notice, until the condition is clear. Normal
cancellation conditions will apply.
6.
Bitches in season will not be able to attend sessions until their season has finished.
7.
We will require sight of the vaccination certificate prior to commencement of session. Dogs cannot be swum
without up to date vaccinations, unless a valid reason can be provided.
8.
Please wear sensible clothing & shoes, ensuring that you don’t mind getting wet … your dog will take great
pleasure in shaking all over you after his/her dip in the pool!
9.
Owners are requested not to feed their dog for at least 3 hours before attending an appointment and to ensure
that the dog has been to the toilet before arriving. We also advise not to feed for at least 2 hours after swimming.
10. Do not stop any medication unless advised by your vet, even if you see an improvement in your dog’s mobility.
11. When not swimming, all dogs will be kept under control and must be on a lead at all times.
12. It is the owner’s responsibility to poop scoop after their dogs whilst on our premises.
13. Chesterfield Hydrotherapy Referral Centre cannot be held responsible for any loss or injury to any person or
animal, howsoever caused, whilst on our premises.
14. Chesterfield Hydrotherapy Referral Centre cannot be held responsible for any loss or damage to vehicles or
personal property, howsoever caused, whilst on our premises.
15. We reserve the right to use any video footage or photographic stills taken during sessions.
16. Please do not leave dogs in your car in hot weather - even warm weather can be dangerous to dogs. You are
able to bring them into the poolroom on a lead and under control.
17. We reserve the right to muzzle any dog that shows aggression during the session. We reserve the right to refuse
to swim dogs that are aggressive towards us at the pool. Owners are responsible to keep their dogs under control
in such circumstances & will be held liable for any damage or injury caused.
18. We reserve the right to cancel any appointments after such incident as a dog defecating in the pool or situations
beyond our control (a power-cut for example) purely for Health & Safety reasons to prevent risking the health of
any dog / owner. For this reason please make sure that we have a mobile contact number. No compensation will
be paid in such circumstances as it will only be done for reasons beyond our control. However we will endeavour
to re-schedule your cancelled appointment.
19. We reserve the right to refuse the treatment of any dog aggressive beyond control or whose owner is rude / abusive
to our staff.
Document1
16/04/2014
Chesterfield Hydrotherapy Referral Centre – Foxwood Close – Foxwood Industrial Estate – Chesterfield – S41 9RB
Tel: -01246 384513 – www.Chesterfieldhydrotherapy.co.uk
Document1
16/04/2014