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