Intake Form – Pawsiotherapy

Date (mm-dd-yyyy) *

Owner name *

First

Last

Phone number *

Email *

Address *

Canine client's name *

Canine birthdate (mm-dd-yyyy) *

Breed *

Sex *

Male
Female

Veterinarian name *

Veterinarian clinic *

Veterinarian phone number *

Can we have your permission to send and receive reports from your Veterinarian periodically to maintain continuity of care? *

Yes
No

Please select the service(s) you are interested in *

Physiotherapy
Massage
Seniors Fitness Class

What area of the body or condition would you like to address? *

Tell us a little about how we can help.

Please list all diagnoses, medical investigations, and treatments the canine client has had for the present condition. *

Please include all relevant medical history and pertinent results to the best of your knowledge. We will conduct a thorough review of the canine client's medical history and consult your Veterinarian (with consent) prior to your first assessment.

How did you hear about us? *

We love rufferals, let us know who we can thank for connecting us!

Informed consent for information sharing *

I give my informed consent to Pawsiotherapy to release and share information with respect to my pet’s care with my Veterinarian as listed above. I understand that my consent may be amended or revoked in whole or in part at any time by providing written notice to Pawsiotherapy, and that revoking consent may have additional consequences such as withdrawal of treatment.
I do not consent.

Please list any other health care professionals or otherwise you consent to Pawsiotherapy releasing and sharing information with in respect to your pet's care. *

You might include a Massage Therapist, Naturopathic Doctor, Chiropractor, Rehab Vet Tech, etc.

Photo Consent *

I hereby authorize any images or video footage taken of myself and/or my pet, in whole or in part, individually or in conjunction with other images or video footage, to be used by Pawsiotherapy for media purposes including promotional presentations, marketing campaigns and advertising. I also authorize and media material created by myself within Pawsiotherapy. I waive rights to privacy and compensation, which I may have in connection with such use of my name and likeness, including rights to be written copy that may be created in connection with image or video production, editing and promotion therewith.
I do not consent.

Cancellation, late & no show policy *

Cancellations must be made 24 hours prior to the scheduled time of the appointment. If the client and owner will be late for a session, a phone or text message notification is appreciated. If the client and owner are more than 15 minutes late the session will be forfeit and the full rate will be charged. No shows and cancellations without minimum 24-hours notice will result in the session being forfeit and the full rate charged. By clicking the box below I confirm, that I have read, understood, and agree to adhere to the cancellation, late & no show policy as outlined above.

Informed consent to assess & treat *

I (owner) hereby consent to canine physio and rehabilitation assessment and treatment for the canine client as documented above. Treatment and assessment techniques may include, but are not limited to: manual techniques, joint mobilizations and manipulations, therapeutic exercise, hydrotherapy, electrotherapeutic and non electrotherapeutic modalities, as well as other techniques and procedures the treating therapist determines may improve the clients physical function. Your therapist will explain the benefits, side effects and potential complications of each chosen technique before use. Throughout your pet’s rehabilitation program, any questions or concerns you have about recommended treatment or assessment techniques must be shared with your therapist immediately so he/she can explain the treatment rationale and/or modify your pet’s program appropriately. If at any time you choose not the participate in the course of treatment, please tell your therapist immediately. I (owner) hereby freely consent to participate with the canine client in the physical and functional assessment and recommended treatment program (based on the client’s medical history, diagnosis, symptoms and assessment results) delivered by my therapist, having been informed of the following: what to expect in the assessment and treatment; who will be performing the assessment and treatment; the reasons/indications for the assessment and treatment; the alternatives to having the treatment; any potential risks and/or side effects of having the treatment; what may happen if my pet does not have the assessment/treatment. I understand and agree with the criteria above and as such agree to participate with the canine client as documented above in an assessment and treatment program. My consent is voluntary for the entire course of assessment and treatment for the canine client's condition(s) commencing on the date indicated above. I understand that I may ask questions at any time and that I may withdraw my consent in writing from assessment and treatment at anytime and for any reason, with the exclusion of actions already taken.