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Pet Parent Questionnaire for Physical Rehabilitation

Disclaimer

PAYMENT IS REQUIRED IN FULL AT THE TIME SERVICES ARE RENDERED. ACCEPTABLE FORMS OF PAYMENT ARE CASH, AMEX, VISA, MASTERCARD, DISCOVER, CARECREDIT, AND SCRATCHPAY (CHECKS WILL NOT BE ACCEPTED).

Owner Name

Address:

Client Phone Number

Pet's Name

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

Yes

Flooring type 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.

(Please check one)

Untitled multiple choice field

I GIVE Gold Coast Center for Veterinary Care permission to take photos/videos and possibly write about my pet’s story, including my pet’s name, on their social media web pages, websites, and possibly in their marketing.

I DO NOT GIVE Gold Coast Center for Veterinary Care permission to take photos/videos and possibly write about my pet’s story, including my pet’s name, on their social media web pages, websites, and possibly in their marketing.

Signature

Date

Check our Facebook and Instagram pages for updated blogs and patient stories!