Canine Rehab Questionnaire

Interested in a rehab consultation? Fill out some info and we will be in touch shortly!

Name

First Name

Last Name

Phone

(###)

###

####

Pet's name

Pet's breed

Pet's Age

Reason for rehab

Please provide your pet's diagnosis or current condition that makes you interested in rehab. Include any evidence of pain that you notice in your pet.

How long has this problem been going on?

Has it gotten worse, better, or stayed the same since your first noticed it?

Describe your pet's current daily activity.

Please note how activity has changed, if applicable.

What kind of flooring does your pet encounter at home?

Slick floors vs. carpet, and make note of any steps (full flight, carpeted or not, etc).

What other conditions or diagnoses does your pet have?

Pet's current medications

Provide medication and supplement information

Previous Vet Care

Who should we contact for your pet's complete medical history?

Hydrotherapy release

Hydrotherapy is conducted in an underwater treadmill filled with treated water, which is regularly refreshed to maintain cleanliness. If your pet defecates while using it, the treadmill must be drained, cleaned, and sanitized, which disrupts our schedule and takes over an hour. To help us avoid these disruptions, please ensure your dog has a chance to defecate before their rehab appointment. Notify our staff if your dog has had diarrhea in the past 24 hours. A cleaning fee may be added to your bill in the event of an accident. I agree to these terms (please write your name to electronically sign below):