Thank you for taking the time to complete the patient information on this form.
Client Name
Clinic Name Name of Veterinarian Clinic Street Address City Business Phone Business Fax Business Email
Patient's Name Breed Age
Does this patient have a history of cardiac disease? YesNo
Has this patient had a recent surgery? If so please indicate type and date performed
Please list any previous surgeries for this patient
Does this patient have any diseases or disorders? If so please describe.
Is there any other information pertinent to treating this patient with Hydrotherapy?
Are there any health conditions that would contraindicate swimming - if so please describe
Please indicate if there are any instructions pertaining to the treatment of the Patient.
Please list any medications the patient is currently taking.
Does the patient have any allergies?
