Animal Medical Clinic- Rehabilitation History Form

Name(Required)

Owner(Required)

Species(Required)

Breed(Required)

Color(Required)

Age(Required)

Sex(Required)

Weight(Required)

Address(Required)

Phone(Required)

History:

Why is your pet being seen at the clinic today?(Required)

How long has your pet has this problem?(Required)

Was there an initial traumatic incident?(Required)

Have you noticed any progression or improvements in the past, since you first noticed your pets injury?(Required)

Functional Questions:

What is your pet’s current activity level (compared to when they were one year old)?(Required)

Is your pet allowed on the furniture/bed? Is this difficult for them?(Required)

What type of flooring do you have (hardwood, tile, linoleum, carpet)?(Required)

Do you have stairs in or around your home? How many?(Required)

Does your pet have a difficult time rising from a laying position?(Required)

Does your pet become exhausted easily with exercise?(Required)

What kind of daily exercise does your pet receive?(Required)

Have you been referred from another clinic?(Required)

Yes

No

Non-Compete Agreement

If referred to Animal Medical Clinic for our Rehabilitation and Pain Management, and/or Our Weight Loss program please complete.

+Name:(Required)

Species:(Required)

Breed:(Required)

Color:(Required)

Age:(Required)

Sex:(Required)

Weight:(Required)

Client ID #:(Required)

Owner's name:(Required)

First Last

Phone(Required)

NON-COMPETE AGREEMENT

I have been referred to this practice by Dr(Required)

from Veterinary Clinic/Hospital(Required)

and consider him/her to be my primary care veterinarian. I understand that I am seeking services at CARPM for rehabilitation, chiropractic or acupuncture purposes. The staff at CARPM will communicate with my primary care veterinarian and if she feels that any non-emergency veterinary diagnostics are needed I will return to my primary care veterinarian to receive these services.

I agree that I will not seek veterinary medical services, diagnostic support and or request any other veterinary support other than that related to physical rehabilitation from our doctors at CARPM. Occasionally exceptions can be made but only with written consent from the referring primary care veterinarian.

Date(Required)

Client Name and Signature:(Required)

History:

Functional Questions:

Questionnaire Regarding your Dog’s Function at Home

Positive Behaviors

Negative Behaviors

Locomotion

Non-Compete Agreement

NON-COMPETE AGREEMENT