Veterinary Referral Form

CUMBRIA CANINE HYDROTHERAPY CENTRE

CLIENT REGISTRATION FORM

Name

Address

Town

Postcode

Tel. No. Email

VETERINARY DETAILS (This section MUST be completed and signed by the dog's Veterinary Surgeon)

Veterinary Surgeon

Practice

Address

Tel. No.
Summary of the dog's injury/condition, areas of caution, comments etc., Is the Dog on medication, if so what?

IN YOUR OPINION, IS THE DOG NAMED ABOVE IN A SUITABLE STATE OF HEALTH TO UNDERGO HYDROTHERAPY TREATMENT YES / NO * Signature_____________________Date ____/____/____ * Please delete as applicable

OWNER'S DETAILS 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. BREED OF DOG .........................................................AGE........................... Signature________________________________ Date____/____/____

Office Use Only

Client No.

Start Date

Programme

Please click HERE for a printable copy of this form