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PET PARENT QUESTIONNAIRE
FOR PHYSICAL REHABILITATION

Owner Name:

Address:

Client Phone Number:

Pet's Name :

Species:

Breed:

Sex:

Best Number to be reached at:

Patient History:
Chief complaint noted at home (i.e.- not using a limb, falling, slipping, weakness):

Current Medications and supplements:

Please describe any and all pain behaviors exhibited. (For example-crying, licking, panting, limping, or restlessness):

Specific tasks that need to be performed at home (i.e.-stairs, obstacles):

Any difficulty urinating or defecating? Is he or she able to squat or lift leg normally to urinate and defecate?

Normal activity level:

Flooring at home:

Known Allergies:

Current diet and amount given:

Additional medical conditions:

Any other pets at home?:

Current sleeping arrangements:

Most important question: What are your goals with rehabilitation?

Special Notes:

How did you hear about our Facility?

Photo Release Form

Photo/Video Release Gold Coast Center for Veterinary Care is asking for your consent to take photos/videos and possibly write about your pet’s story on our social media web pages, websites, and in our marketing. These postings can help to further educate/promote awareness for the many types of treatments, success stories and interesting cases we see here. *Note- Gold Coast Center for Veterinary Care will never share any of your personal, client information over the internet.
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Signature:

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Date:

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