Veterinary Referral Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" bgproperties="fixed" background="052cd663.jpg"> <div> <B><U>Cumbria Canine Hydrotherapy Centre</U></B><B>     </B><FONT SIZE="2" COLOR="#993366" FACE="Arial" ><B> </B><A HREF="index.htm" TARGET="_top" TITLE="Cumbria Canine Hydrotherapy Centre"><U><B>home</B></U></A></FONT></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="About Cumbria Canine Hydrotherapy Centre"><U><B>About Cumbria Canine Hydrotherapy Centre</B></U></A><B>   |   </B><A HREF="id18.htm" TARGET="_top" TITLE="Hydrotherapy"><U><B>Hydrotherapy</B></U></A><B>   |   </B><A HREF="id19.htm" TARGET="_top" TITLE="Facilities"><U><B>Facilities</B></U></A><B>   |   </B><A HREF="id20.htm" TARGET="_top" TITLE="Treatment Programmes"><U><B>Treatment Programmes</B></U></A><B>   |   </B><A HREF="id21.htm" TARGET="_top" TITLE="Case Studies"><U><B>Case Studies</B></U></A><B>   |   </B><A HREF="id22.htm" TARGET="_top" TITLE="Contact Us"><U><B>Contact Us</B></U></A><B>   |   </B><A HREF="id23.htm" TARGET="_top" TITLE="Photo Album"><U><B>Photo Album</B></U></A><B>   |   </B><A HREF="id27.htm" TARGET="_top" TITLE="Links"><U><B>Links</B></U></A><B>   |   </B><B>Veterinary Referral Form</B><B>   |   </B><A HREF="id35.htm" TARGET="_top" TITLE="Terms Conditions"><U><B>Terms & Conditions</B></U></A><B>   |   </B><A HREF="vet_form.htm" TARGET="_top" TITLE=" "><U><B> </B></U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" bgproperties="fixed" background="052cd663.jpg"> <div> <IMG SRC="055c5790.jpg" border=0 ALIGN="BOTTOM" HSPACE="0" VSPACE="0" width="197" height="121"></div> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I> <A NAME="veterinary_referral_form"><IMG BORDER="0" SRC="1x1.gif" ALIGN="bottom" HSPACE="0" VSPACE="0" width="1" height="1" ></A></I><I>Veterinary Referral Form</I></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B>CUMBRIA CANINE HYDROTHERAPY CENTRE</B></div> <bR> <bR> <div> CLIENT REGISTRATION FORM     </div> <div>                      </div> <div> Name</div> <bR> <bR> <div> Address     </div> <bR> <div> Town</div> <bR> <div> Postcode</div> <bR> <div> Tel. No.                         Email</div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> VETERINARY DETAILS (This section MUST be completed and signed by the dog's Veterinary Surgeon)</div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="548" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 39 WIDTH="132"><div> <B>Veterinary Surgeon</B></div> </tD> <tD VALIGN=TOP WIDTH="403"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="39" ALIGN="bottom" WIDTH="403" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="538" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="132"><div> <B>Practice</B></div> </tD> <tD VALIGN=TOP WIDTH="393"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="393" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="539" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="132"><div> <B>Address</B></div> </tD> <tD VALIGN=TOP WIDTH="394"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="394" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="539" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ROWS" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="132"><div> <B>Tel. No.</B></div> </tD> <tD VALIGN=TOP WIDTH="394"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="394" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 154 WIDTH="132"><div> <B>Summary of the dog's injury/condition, areas of caution, comments etc., Is the Dog on medication, if so what?</B></div> </tD> <tD VALIGN=TOP WIDTH="394"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="154" ALIGN="bottom" WIDTH="394" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></B></div> <bR> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="538" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 72 WIDTH="528"><div> <B>IN YOUR OPINION, IS THE DOG NAMED ABOVE IN A SUITABLE STATE OF HEALTH TO UNDERGO HYDROTHERAPY TREATMENT YES / NO </B><FONT SIZE="1" COLOR="#0000FF" FACE="Arial" ><B>* </B></FONT>Signature_____________________Date ____/____/____ <FONT SIZE="1" COLOR="#000000" FACE="Arial" >* Please delete as applicable</FONT></div> </tD> </tR> </TABLE></div> <bR> <bR> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="536" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 80 WIDTH="526"><div> <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>OWNER'S DETAILS </B></FONT>I/WE DECLARE THAT I/WE AM/ARE THE LEGAL OWNER(S) OF THE DOG NAMED ABOVE AND THAT THE  INFORMATION SHOWN ON THIS FORM IS CORRECT. FURTHER I/WE HAVE READ & FULLY ACCEPT THE CCHC TERMS & CONDITIONS.       <B>BREED OF DOG .........................................................AGE........................... </B> <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" >Signature________________________________ Date____/____/____ </FONT></div> </tD> </tR> </TABLE></div> <bR> <bR> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="534" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 39 WIDTH="88"><div> <B>Office Use Only</B></div> </tD> <tD VALIGN=TOP WIDTH="171"><div> <B>Client No.  </B></div> </tD> <tD VALIGN=TOP WIDTH="143"><div> <B>Start Date</B></div> </tD> <tD VALIGN=TOP WIDTH="107"><div> <B>Programme</B></div> </tD> </tR> </TABLE></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <I><B><U>Please click </U></B></I><A HREF="vet_form__.htm" TARGET="_top" TITLE=" "><U><I><B><U>HERE</U></B></I></U></A><I><B><U> for a printable copy of this form</U></B></I></div> <div> <A HREF="#veterinary_referral_form" TITLE="Veterinary Referral Form"><U>back to top</U></A></div> </td> </tr></table></body>