Veterinary Consent For Physiotherapy

Please note this form is for Veterinary Surgeons to complete

This online form allows Veterinary Surgeons to refer clients for Online Veterinary Physiotherapy under Raybrook Veterinary Physiotherapy,
hosted by Yorkshire Pooches Therapies.
All clients will have a mandatory 6 week in-person assessment carried out by Yorkshire Pooches Therapies.

Download Consent Form

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 undergo Veterinary Physiotherapy. 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

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