<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" height=90 BGCOLOR="#006699" TEXT="#080000" bgproperties="fixed" background="052cd681erlcgo.jpg"> <div> <B>Cumbria Canine Hydrotherapy Centre</B><FONT SIZE="5" COLOR="#FFCC66" FACE="Arial" ><B>       </B></FONT><FONT SIZE="2" COLOR="#FFFFCC" FACE="Arial" ><B> </B></FONT><FONT SIZE="2" COLOR="#993366" FACE="Arial" ><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><A HREF="id29.htm" TARGET="_top" TITLE="Veterinary Referral Form"><U><B>Veterinary Referral Form</B></U></A><B>   |   </B><A HREF="id35.htm" TARGET="_top" TITLE="Terms Conditions"><U><B>Terms & Conditions</B></U></A><B>   |   </B><B> </B></div> <div> </div> </td> </tr><tr> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I> <A NAME="_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></I><I> </I><FONT SIZE="4" COLOR="#0000FF" FACE="Arial" ><B>CUMBRIA CANINE HYDROTHERAPY CENTRE</B></FONT><FONT SIZE="1" COLOR="#0066CC" FACE="Arial" ><B>.</B></FONT></div> <div> CLIENT REGISTRATION FORM     </div> <div>                      </div> <div> Name.......................................................................</div> <bR> <div> Address............................................................................................................................................................. </div> <bR> <div> Town.................................................................................................................................................................</div> <bR> <div> Postcode...........................................................................................................................................................</div> <bR> <div> Tel. No:................................................Email.....................................................................................................</div> <bR> <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="625" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ROWS" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 39 WIDTH="132"><div> <B>Veterinary Surgeon</B></div> </tD> <tD VALIGN=TOP COLSPAN=2 WIDTH="402"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="39" ALIGN="bottom" WIDTH="402" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="73"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="39" ALIGN="bottom" WIDTH="73" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="132"><div> <B>Practice</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> <tD VALIGN=TOP WIDTH="7"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="7" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="73"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="73" HSPACE="0" VSPACE="0"></tD> </tR> <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> <tD VALIGN=TOP WIDTH="7"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="7" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="73"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="73" HSPACE="0" VSPACE="0"></tD> </tR> <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> <tD VALIGN=TOP WIDTH="7"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="7" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="73"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="73" 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> <tD VALIGN=TOP WIDTH="7"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="154" ALIGN="bottom" WIDTH="7" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="73"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="154" ALIGN="bottom" WIDTH="73" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <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> <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> <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> <bR> </td> </tr></table></body>