24/7 EMERGENCY AND SPECIALTY REFERRAL VETERINARY HOSPITALS
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Rehab Admission Form
CLIENT INFORMATION
Full Name *
Phone *
Address *
City *
Province *
Postal Code *
Email Address *
Preferred Contact Method *
Phone
Email
Emergency Contact Full Name *
Cell Phone *
Relation to Client *
Referring Veterinary Hospital/Clinic *
Referring DVM Name *
Pet Insurance *
Yes
No
PATIENT INFORMATION
Patient Name *
Species *
Birth Date/Age *
Breed *
Gender *
Please Select
Male
Male, Neutered
Female
Female, Spayed
Weight (indicate kgs or lbs) *
Is your pet up to date on the Rabies Vaccine? *
Yes
No
Please indicate the primary issue for which your pet needs Rehab *
When did the issue start? *
Do any activities make the issue better or worse? *
Current Mobility Status *
Walks unassisted
Assisted
Wheelchair
Non-ambulatory
Other
Current Medications and Doses (please include instructions) *
Does your pet have any medication sensitivities or allergies? *
Yes
No
Does your pet take any supplements? *
Yes
No
What type of food does your pet eat? *
How much food do you feed and how often? *
What type of treats does your pet receive? *
Are there any specific treats that they love that may help with their Rehab sessions? *
Does your pet have any diet sensitivities or allergies? *
Yes
No
Does your pet have any other medical conditions? *
Has your pet ever had any surgeries or previous medical issues? *
Does your pet have to navigate stairs (inside or outside the home)? *
Yes
No
What types of flooring does your pet need to navigate at home? *
What is your pet’s daily routine? *
Does your pet participate in any specific classes, sports or jobs? *
Does your pet exhibit fear, anxiety or stress in-clinic or in new environments? *
Yes
No
Do you think your pet is in pain? *
Yes
No
On a scale of 1-10 (1 being little pain, 10 being extreme) what would you rate your pet's pain level? *
Please Select
1
2
3
4
5
6
7
8
9
10
Do you think the pain is constant or intermittent? *
Do they require a muzzle? If yes, please describe. *
Do they require pre-appointment medications? *
Does your pet have any sensitive areas they dislike being touched? *
Are there any procedures your pet has not liked having preformed or seemed difficult for you or staff to do? *
Ex, getting on a scale, certain parts of exams, handling, injections
Are there any other pets at home? If yes, how many and what species? *
Have you noticed any changes in activity or behaviour since the issue began? *
Has your pet had any urinary or fecal incontinence? *
Yes
No
Do they seem aware when passing urine or stool? *
Yes
No
Does your pet squat or lift a leg to urinate? *
Is your pet able to hold a squat to defecate? *
Yes
No
Has your pet had Rehab before? *
What are your goals for Rehab? *
Is there anything else that you feel would be helpful to know prior to the consultation? *
CONSENTS
I hereby consent to and authorize the treatment and/or services that Lakeshore Animal Health Partners, Rehabilitation Team recommends for my pet. I understand that rehabilitation may include, but is not limited to, therapeutic exercises, manual therapy, laser therapy, hydrotherapy, and acupuncture. The purpose of these treatments is to support the physical recovery, mobility, and overall well-being of my pet. I accept that there is no guarantee of effectiveness of treatment. I understand the risks that may be involved and that it is not possible to anticipate all risks or complications. This may include but not limited to: minor pain or soreness, transient weakness or lethargy post-treatment, minor bleeding or bruising, infection, bending/breaking of a needle, possible perforation of internal organs/cavities, seizure, burn. Accidental ingestion of a needles is a risk in certain pets and may require further treatment including surgery. I understand that any treatment required for any complications that may occur are my own financial responsibility.
Treatment Consent *
I consent
I do not consent
I consent to photographs and/or videos of my pet being taken for treatment tracking purposes and understand that some images may be used for educational or marketing purposes (e.g., social media, website, brochures). My name and personal identifying details will not be disclosed.
Photos/Videos Consent *
I consent
I do not consent
Client Signature *
Date *
Calendar
Today
Security Question *
I HAVE READ AND UNDERSTOOD THE
PRIVACY POLICY
*
Back
Menu
About
Careers
News
Toronto AHP
Services
Our Team
Photo Gallery
My Pet is in the Hospital
Patient Admission Form
Lakeshore AHP
Services
Our Team
Photo Gallery
My Pet is in the Hospital
Patient Admission Form
Rehab Admission Form
Referrals
Toronto AHP Referrals
Lakeshore AHP Referrals
Rx Refills
Contact
24/7 EMERGENCY AND SPECIALTY REFERRAL VETERINARY HOSPITALS