VETERINARY CONSENT / REFERRAL FORM
Pamela Marsh MSc Vet Phys ACPAT ‘A’
Canine Physio-Hydro Centre
The Bingham Therapy Practice
1, Long Acre East
Bingham,
Nottinghamshire
NG13 8BY
Tel 01949 837111
www.caninephysiotherapy.co.uk
Referrals to
pmarsh-physiohydro@hotmail.com
Owner’s Details
Dog’s Details
Vaccinations up to date Yes / No
Name
Breed
DOB
Sex
Insurance Details Yes / Not applicable
Postcode
Tel No
Mobile
Neutered Yes / No
TO BE COMPLETED BY VETERINARY
SURGEON
Referring Veterinary Surgeon
Name
Tel / Fax No
Email
Medical Details / Procedures
I give my consent for the above named
animal to receive Physiotherapy and/or
Hydrotherapy
Vet Signature
Name
Address
Practice Name & Address
Specific recommendations
Current medication / Areas of caution
I/We declare that we are the legal
owner(s) of the above named dog and
that the information shown on this form is
correct. I/we confirm that I/we have read
and fully accept the Terms & Conditions
printed overleaf
Print Name
Signature
Date
Print Name(s)
Date
Pamela Marsh – Chartered Veterinary Physiotherapist
Canine Physio-Hydro Centre
Terms and Conditions
1.
No animal will be treated without the prior authorisation of their Veterinary
Surgeon
2.
Whilst every care is taken of each dog during treatment, it is done so
entirely at the owner’s risk
3.
A current vaccination certificate or equivalent is required for every dog
receiving treatment
4.
All treatments are to be paid for at the time of the session. (Debit / credit
cards are not accepted). Receipts will be issued on request
5.
Please ensure that your dog arrives as clean as possible for their session
6.
In the event of a cancellation 24 hrs notice is required otherwise the full
charge will be made
7.
Any animal with a suspected infectious or contagious condition such as those
affecting the skin, ears or eyes or with a chronic cough will not be treated
without the specific written authorisation of the referring Veterinary Surgeon
8.
Dogs must be kept under control and on a lead at all times whilst on the
premises
9.
Owners are requested not to feed their dog within 3 hours of the therapy
session appointment time
10.
Dog ‘toileting’ is not permitted on the premises. However, there are adequate
public dog areas close nearby with the appropriate disposal bins – please
inquire for further details
11.
A surcharge of £40.00 will be charged in the event of a dog defaecating in the
pool. This is to cover the cost of shutting the facility down and cleaning
12.
On arrival, please remain in the car with your dog.
when the facility is ready for your session
13.
Pamela Marsh will ensure that adequate public liability and professional
indemnity insurance is kept up to date at all times
14.
No responsibility will be accepted for any loss or damage to vehicles or
personal property, however occasioned, whilst on the premises
You will be advised