Patient Registration Form

This form is for new clients of Ceola Reece Veterinary Physiotherapy to register their animal/s for physiotherapy care.

If you have any questions or concerns, please contact Ceola directly:

Email: info@crvetphysio.com
Phone: 07845 359715

Client Details

First name

Last name

Phone

Email

Full address where your horse or dog lives (eg. yard address or home address)

Patient Details

Please provide important initial information about the animals you wish to register with me for physiotherapy.

How many animals are you registering with me today? If you are registering more than 2, please submit the form then fill it out again with the other animals details.

Patient One

Patient Name

Patient Species

Patient Gender

Patient Date of Birth

Day

Month

Year

What is the main reason you are seeking physiotherapy out for your animal? Please include details of any ongoing medical concerns

Please provide details of any past medical history, including any injuries, illnesses, surgeries, diagnostic procedures or investigations etc.

Is your animal on any medication, if so, what medication is this?

Veterinarian Details

Please provide details of your animals veterinary practice.

Legally, all patients must be registered with a Veterinary Surgeon before they can start physiotherapy. Is your animal/s registered with a vet?

Yes

No

Name and address of the veterinary practice where your animal is registered

Email address or telephone number of your veterinarian

Declarations and Important Information

Please read the following sections carefully as they provide important legal considerations relevant to registering your animal for physiotherapeutic care with Ceola Reece Veterinary Physiotherapy.

If you have any questions or concerns, please contact Ceola directly:

info@crvetphysio.com
07845 359715

In accordance with the Veterinary Surgeons Act, I may need to get veterinary consent from your vet before we can start physiotherapy with your animal. Do you consent to me contacting them to organise this?

Yes, that's fine.

Can we speak about this further please?

To provide high quality veterinary physiotherapy care, I like to maintain regular communication with your vet, including sending reports. Do you consent to this?

Yes, that's fine at any time

I'd prefer you'd let me know before each time you speak with my vet

Do you agree to follow the payment terms and cancellation policy found in my Terms and Conditions on my website?

Yes

Can we speak about this further please?

Would it be okay if I used images and videos of your animal on my website, social media and for educational purposes? I will of course always treat these with the upmost respect and decency.

Yes, that's fine

I'd prefer you didn't use images/videos of my animal for these purposes

Provide your name below, as an electronic signature. By signing your name below, you agree to all the declarations and terms outlined in this form and my full Terms and Conditions found on my website.