Client Name *

First

Last

Client Phone Number *

Client Email *

Client Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Name *

Primary Veterinarian *

What medications and supplements is your pet on (include any joint supplements)? *

Current diet and appetite. Please note any allergies or food sensitives *

Presenting problem/surgery performed and date performed *

Do you have any concerns about your pet’s recovery/current state so far?

Is your pet able to squat/lift leg normally to urinate or defecate? *

Yes
No

Current activity level (i.e. leashed walks for potty breaks outside, daily walks, etc.) and prior activity level, before injury/surgery? *

Describe your pet’s environment? (Type of floors, stairs, furniture they climb on, fenced yard, access to dog door, etc.) *

On a scale of 0-4 how much pain is your pet in?

Selected Value: 0

What painful behaviors are you seeing (such as crying when rising, appearing stiff when moving, licking, panting, etc.)? *

What are your specific goals for your pet (some examples may include hiking, swimming, sports, or just able to achieve daily walks comfortably)? *

Scheduling Availability

Tech Times

Rehabilitation Therapy Consent:

I authorize that I am the owner or legal guardian of the pet named above. I hereby provide my informed consent for the initiation of rehabilitation therapy for my pet with Trek Veterinary Surgery.

I acknowledge the following:

1. I have been informed about the nature, purpose, risks, and potential benefits of rehabilitation therapy for my pet.

2. I understand that the therapy may not guarantee a specific outcome and that the response to treatment may vary among individuals.

3. I understand that the therapy may involve physical manipulation and exercise, which could result in some level of discomfort or pain for my pet.

4. I consent to the administration of rehabilitation therapy for my pet under the supervision of licensed and trained veterinary professionals.

5. I understand that I am encouraged to remain present during the therapy sessions, and I will be informed of my responsibilities and any home care requirements.

6. I agree to follow all recommendations and instructions provided by the veterinary professionals for the well-being of my pet.

7. I understand that Trek Veterinary Surgery is not liable for any personal injury to myself during rehabilitation sessions performed both with the rehabilitation technician and at home personally between sessions.

8. I understand that the cost of rehabilitation therapy will be discussed separately, and I will be responsible for any associated fees.

Rehabilitation Therapy Consent: I authorize that I am the owner or legal guardian of the pet named above. I hereby provide my informed consent for the initiation of rehabilitation therapy for my pet with Trek Veterinary Surgery. I acknowledge the following: 1. I have been informed about the nature, purpose, risks, and potential benefits of rehabilitation therapy for my pet. 2. I understand that the therapy may not guarantee a specific outcome and that the response to treatment may vary among individuals. 3. I understand that the therapy may involve physical manipulation and exercise, which could result in some level of discomfort or pain for my pet. 4. I consent to the administration of rehabilitation therapy for my pet under the supervision of licensed and trained veterinary professionals. 5. I understand that I am encouraged to remain present during the therapy sessions, and I will be informed of my responsibilities and any home care requirements. 6. I agree to follow all recommendations and instructions provided by the veterinary professionals for the well-being of my pet. 7. I understand that Trek Veterinary Surgery is not liable for any personal injury to myself during rehabilitation sessions performed both with the rehabilitation technician and at home personally between sessions. 8. I understand that the cost of rehabilitation therapy will be discussed separately, and I will be responsible for any associated fees. *

I understand and accept.

By checking below, I agree to the following Cancellation Policy:

We understand that plans can change, and sometimes, you may need to cancel or reschedule your reservation. Please take a moment to review our cancellation policy below:

-Cancellations must be made at least 48 hours, or more, before your scheduled appointment date.

-Cancellations made less than 48 hours before your scheduled appointment date will result in a $150 cancellation fee, or forfeiture of one session from a pre-purchased treatment package.

If you have any questions or need assistance, please don't hesitate to reach out to our rehabilitation team at [email protected].

By clicking here, I agree to the following Cancellation Policy: We understand that plans can change, and sometimes, you may need to cancel or reschedule your reservation. Please take a moment to review our cancellation policy below: -Cancellations must be made at least 48 hours, or more, before your scheduled appointment date. -Cancellations made less than 48 hours before your scheduled appointment date will result in a $150 cancellation fee, or forfeiture of one session from a pre-purchased treatment package. If you have any questions or need assistance, please don't hesitate to reach out to our rehabilitation team at [email protected]. *

I understand and accept.

Rehab Initial Evaluation Questionnaire