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Rehab Registration Form

**PLEASE NOTE: We are taking new patients, but we are currently booking out a few weeks for consults in order to be able to facilitate the best patient care!

Please allow 3-5 days to be contacted about an appointment! We are getting patients in as soon as we can!**

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Owner Information

Owner Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Owner Email:(Required)

Owner Phone:(Required)

Spouse/Co-Owner Information

Spouse/Co-Owner Owner Name(Required)

First Last

Spouse/Co-Owner Email:(Required)

Spouse/Co-Owner Phone:(Required)

Patient Information

Patient Name:(Required)

Age:(Required)

Color:(Required)

Breed:(Required)

Sex:(Required)

Spayed/Neutered/Intact:(Required)

What is your pet's current diagnosis? (Required)

Write "unknown" if no diagnosis or unsure

What is the reason for seeking rehabilitation for your pet?(Required)

Post-surgery

Pre-surgery

Arthritis

Overweight

Other

Referring Surgeon/Doctor/Hospital(Required)

General Practitioner Doctor/Hospital (if different from above)(Required)

List 'N/A" if same as above

Duration of current diagnosis/concern, and areas affected(Required)

List 'N/A" if same as above

Surgery and/or Injury Date*(Required)

Any other medical history we should be aware of?*(Required)

Write "N/A" if none

CURRENT level of activity(Required)

Sedentary - out to eliminate only

Light walks (1-3 times per day for under 10 minutes)

Moderate (1-3 times per day for 10-30 minutes)

Heavy (1-3+ times per day for 30 or more minutes)

Other

PREVIOUS level of activity(Required)

Sedentary - out to eliminate only

Light walks (1-3 times per day for under 10 minutes)

Moderate (1-3 times per day for 10-30 minutes)

Heavy (1-3+ times per day for 30 or more minutes)

Other

Activities Requiring Assistance(Required)

None

Walking

Getting up

Getting into car

Urination/defecation positioning

Other

Has your pet had any previous rehabilitation therapies?(Required)

If your pet does not have any previous rehab therapies, please put 'N/A'

Home Flooring(Required)

Hardwood

Tile

Carpet

Linoleum

Area rugs

Other

Select any where your pet spends majority of their time

Do you have stairs? If yes, how many does your pet normally need to use?(Required)

Favorite Types of Treats(Required)

TREAT?!?! Did someone say TREAT?!?! Hooray!

Peanut Butter

Spray Cheese

Freeze Dried Protein Treats (Beef, Liver, Chicken)

Chewy/Soft Treats

Crunchy treats

Other

select all that apply

Any dietary restrictions/allergies?(Required)

We utilize lots of treats for positive reinforcement!

Current Appetite(Required)

Normal

Increased

Decreased

Any Vomiting?(Required)

Any Diarrhea?(Required)

Does your pet have full control of his/her bowels?(Required)

Does your pet have full control of his/her bladder?(Required)

Do you have any concerns/restrictions performing exercises with your pet at home?(Required)

Rehabilitation Preference(Required)

Any modalities recommended

Hydrotherapy

Rehabilitation (Floor Exercises)

Acupunture

Massage

Other

Please check all that apply

Family Expectations for Pet(Required)

Pain free/Pain Control

Able to eliminate without assistance

Short walks

Long walks

Home activities - stairs, jump on and off furniture, active in the yard, etc.

Weekend activities - i.e. beach hiking camping swimming

Return to full function

Other

Please select all that apply

Please provide any other important information not included above:(Required)

Multimedia Release(Required)

NH Pet Physical Rehabilitation Center often records photographs and videos of patients while at the clinic for the purposes of education, promotion, or advertising.

Attach Medical Records and Radiographs(Required)

Max. file size: 15 MB.

Please attach any discharge instructions or medical history here. Please ask your veterinarian and/or surgeon to email pertinent records and history to info@nhpetrehab.com

Owner Signature(Required)

First Last

Consent(Required)

I agree to the below financial policy

Payment is due at time of service. Forms of payment accepted include cash, all major credit cards, Care Credit, and Scratchpay. Checks are not accepted.

Consent(Required)

I agree to the below policy

I, the undersigned, certify that I am 18 years of age or older and I am the legal owner (or authorized agent of the owner) of the patient listed above. I agree to assume financial responsibility for all charges incurred and agree to pay such charges at the time of services rendered. I also understand that personal checks are not accepted. I am responsible for all interest and collection fees on any unpaid balance, as well as reasonable attorney fees and court costs associated with collection of unpaid balances. I acknowledge that the above information is true and accurate to the best of my knowledge.

NH Pet Physical Rehabilitation Center (NHPPRC) is an ABUSE-FREE WORKPLACE. By initialing here, I understand that NHPPRC has a ZERO TOLERANCE policy for profanity and verbal abuse. I further understand that any profane, abusive, or hostile behavior or language directed at any member of the NHPPRC team will result in immediate removal from the hospital, and I will no longer be allowed to bring any of my pets to NHPPRC in the future, for any reason.

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Our Practice
Services
New Clients
- New Client Form
Locations
- Individual Location Page
Resources
Contact Us

Our Practice
Services
New Clients
- New Client Form
Locations
- Individual Location Page
Resources
Contact Us

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