Veterinary Consent Form

Please note this form is for Veterinary Surgeons to complete

Working in conjunction with the Veterinary Surgeons Act 1966

Yorkshire Pooches Therapies Canine Pain Management Clinic
hosts a carefully selected group of qualified professionals,

- IAAT Canine Massage Therapist & Wellness Consultant-
-NAVP Veterinary Physiotherapist-
- Underwater Treadmill Hydrotherapist-

Any further questions or queries, please don’t hesitate to contact me

Name of Veterinary Surgeon

Name of Veterinary Practice

Email address of Veterinary Practice

Telephone Number of Veterinary Practice

Full Postal Address of Veterinary Practice

Name of Owner

Name of Dog

Breed of Dog

Gender and Neuter Status of Dog

Relevant Medical History of Dog

Current Medication

Any additional medical details you believe I should be aware of, prior to the session

VETERINARY SURGEON'S DECLARATION - The animal stated above has no contraindications that hasn't been disclosed and I consent for them to receive treatment by a Yorkshire Pooches Therapies qualified therapist. Please state your name and date

Opt - In as Confirmation

I the Veterinary Surgeon agree for this animal to receive treatment. I do not accept any liability, should injury occur.

Opt - In as Confirmation

I confirm that by filling out the above details and submitting form to Yorkshire Pooches Therapies, that this constitutes as a digital signiture

Please inform Yorkshire Pooches Therapies if you would like us to forward session reports

Yes

Please select the appropriate Therapies

IAAT Canine Massage Therapy

NAVP Veterinary Physiotherapy (Online)

Underwater Treadmill

All of the above

Veterinary Consent Form

✓ DBS Checked