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- Section for Owner -

Dogs Name:

Canine Hydrotherapy:      Canine Acupuncture: 
        (Please tick one or both boxes)

Breed:


Date of birth or approximate age:


Sex:
Female     Neutered-Female     Male     Neutered-Male


Owners Details:

Name:


Address:


City:


Post Code:


Telephone Number:


Cell:


E-Mail:


Is your dog insured?
Yes    No

If so, with which insurance company?


Policy number?



I hereby declare that I am the legal owner of the above named pet and that the information shown on this form is correct and that I consent to the disclosure of clinical information regarding my pet by my veterinary surgeon for the purposes of this referral.

Signed:______________________________________________________Date:______________________
- Section for Veterinarian -

Veterinary Surgeon Name:


Practice Address:

City:


Post Code:


Telephone Number:


E-Mail:

Please provide details of the condition requiring hydrotherapy and/or acupuncture (delete as appropriate) along with any relevant history:


Please provide your recommendation for time to be spent swimming at each session, and any areas of caution or concern:


Specific requirements of hydrotherapy and/or acupuncture for your patient:


Is your patient suffering from any condition, such as heart disease, that would make him unsuitable for hydrotherapy?
Yes    No

Is your patient suffering from any infectious disease or other condition that could pose a risk to other dogs?
Yes    No

Date that your patient had his or her last annual vaccination:


Has your patient had a kennel cough vaccine in the previous year?
Yes    No

In your opinion, is your patient in a suitable state of health to undergo hydrotherapy and/or acupuncture treatment?
Yes    No

Signed:_______________________________________________________  Date:________________________

Please post to: Lucies Farm Ltd., Whitecroft, Colletts Green, Worcester WR2 4RY or give to your client to bring to the first appointment.

Thank you for taking the time to complete this form. We will provide you with a report of your patient's treatment at Lucies Farm.