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Contact Details
Name
*
Email address
*
Telephone.
*
Mobile
*
Address
Dog Details
Dogs Name
*
Breed
*
DOB
*
Vet Name
*
Branch
*
Any other pets in the household
*
Practice Name
*
Telephone
*
Sex
*
Please Select
Male
Female
General Information
What is your dogs current food? (including how often & treats)
*
Please list any current/relevant medical Conditions suffered by your dog
*
How many minutes exercise does your dog receive each day? On or off lead
*
Reason for attending Hydrotherapy
*
Please Select
Fun Swim
Exercise
Rehabilitation
Other
Has your dog ever swum before?
*
Please Select
Yes
No
How did you hear about us?
*
Please Select
Vet
Friend
Leaflet
Internet
Other
Has your dog ever shown signs of aggression to Humans?
*
Please Select
Yes
No
Has your dog ever shown signs of aggression to Other Dogs?
*
Please Select
Yes
No
Please provide details of any known allergies?
*
I understand that hydrotherapy may not help all conditions and as with any physical activity, swimming can involve some risk. I have given all relevant medical and behavioural history above and will inform the centre of any changes to my dogs heath. I authorise Hainault Hydrotherapy to contact the veterinary surgeon named on this form to obtain confirmation that my dog is fit to swim and to discuss any aspects of ny dogs health and treatment.
*
I declare that I am the legal owner of the above named dog, and that the information given on this form is correct. I have read and fully accept the terms and conditions set out by Hainault Hydrotherapy centre.
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