Contact Chingford Hydrotherapy Centre Today - Telephone : 020 8529 0979 | E-mail :

info@chingfordhydrotherapycentre.co.uk

Veterinary Assessment And Referral Form For Suitability To Hydrotherapy

When we receive your registration it will be sent directly to your Veterinary Surgeon for either a signature confirming that your dog is fit to swim or a Vet Referral giving details of your Dogs medical or surgical condition.

Practice Details

Practice Name :
Address :
Telephone Number :			Fax Number :
E-Mail Address :
Referring Veterinary Surgeon :

Animal Details

Name :
Breed :			Colour :
Sex :			Date Of Birth:
Vaccine Expiry Date :
Insurance Company :			Policy Number :

Owner's Details

Name :
Address :
Home Telephone Number :			Mobile Number :
Email Address :

General Health Assessment

Last Examined :
Heart Rate :	Heart Murmur :	Yes No
Weight :	Eyes :
Mobility :
Last Date Of Worming :	Lungs / Respiration :
Skin :	Ears :
Faecal or Urinary Incontinence :	Body Condition And Fitness :
Behavioral Consideration :

Relevant Case History

Give details of any
injury / surgical procedures :

Present treatment including
any medication :

Specific requirements
- aims and goals of hydrotherapy :

I believe that the above named dog is in a suitable state of health to undertake hydrotherapy

Date :