Labradoodle swimming in the hydrotherapy pool

Rehab

Vet Referral Form (Vets Only)

If you are a veterinary practice and you would like to refer a dog for hydrotherapy & physiotherapy, please complete the form below.

If you have any queries, please call 020 8995 2060.

Client Full Name (First names - Surnames)

House/or Flat Number

Address 1

Address 2

Town

County

Post Code

Email:

Mobile Number

Example +44 7712345689

Dog's Full Name

Please enter the surname if it different to clients details above

Breed

If mixed breed, Please state all breeds if known.

Date of Birth

Sex

Radio options for Sex Female Male

Last Record Weight

When was the condition/injury first diagnosed.

Please state the date, the client first come with the condition or injury.

Condition/Injury/Illness (All condition's/injury's/illnesses must be stated on the referral due to insurance protocol). You must complete this section even with attached Medical History Thank you.

Please state all conditions & Injury's on this referral. Thank you

Medication

Behavioural Issues

Please statement any behavioral issues, (Lunges & Growls).

If the dog is registered has a (XL Bully BREED) - We require the Certificate of Exemption, Thank you

Please upload Certificate with the completed form - Please provide any other information here:

Practice Details:

Name of Referring Practice

Address

Contact Telephone Number

Email Address

What date did the client register with you

Treatments:

Please use this section to indicate treatments & if there is any contraindications. Condition or Situation why treatment should not be used. This part is mandatory, you must selection Thank you

Pool Hydrotherapy

Radio options for Pool Hydrotherapy Suitable Any Contraindications (please state)

This part is mandatory, you must selection Thank you

Underwater Treadmill Hydrotherapy

Radio options for Underwater Treadmill Hydrotherapy Suitable Any Contraindications (Please state).

This part is mandatory, you must selection Thank you

Land Based Physiotherapy

Radio options for Land Based Physiotherapy Suitable Any Contraindications (Please state).

This part is mandatory, you must selection Thank you

Class 4 Laser

Radio options for Class 4 Laser Suitable Any Contraindications (Please state).

This part is mandatory, you must selection Thank you

Contraindications

Important, if there is any contraindications, to the below Treatments ( Please state them here):

‘Does the dog have any metal or conductive plates/implants/screws?’

No Yes

If yes, please state

Other Information

Date of Referral

By completing and checking this electronic form you understand that any therapy treatment given to the above animal is the responsibility of the NARCH registered Canine Hydrotherapist based on the information provided.

I understand & acknowledge:

Medical History Please attached all relevant/required Medical History, (PDF format) Thank you. Please note that there is a maximum of 6mb that you can upload, if you extend this the form will not submit.

Veterinarians Signature ONLY. (This form can be completed by a staff member but must be signed off by a vet only).

Full Name of Signature:

DogtownDogtown LTD93 Chiswick High RoadLondonW4 2EF020 8995 2060email us

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"Both day care & grooming is amazing - wouldn't be with anyone else" Paula Jenner

"My dog loves going to Dogtown daycare" Hannah Evans

"Always look after my dog brilliantly" Carolyn W

"Highly recommended" Madelaine Taylor

"I was immediately reassured by the lovely attitude of the staff" Laura Kettle

"I've been bringing our dog to Dogtown East Sheen (Daycare) for several years now. Fantastic team and our dog loves her time there!".... Mark Robertson

"Very friendly and professional" Nikita

"The whole team is very nice and knowledgable" Mimi Adam

"Knowledgeable, professional and a pleasure to deal with" Sasha M

"I’ve been coming to Dogtown for around a year now, to have hydrotherapy for my dog Pickle The team have always been wonderful & friendly, and there has been a massive improvement"..... Katie Hitchcock