Referral Form For Dog Owners Please fill in this form as an owner to refer your dog to CS Hydro-phyiso Ltd for treatment. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Dogs DetailsDog Name *Dog Breed *Dog Colour *Dog Weight (Kg) *Dog Age *Dog Date of Birth (DOB)Dog Gender & Neutering Status *Male (Intact)Male (Neutered)Female (Intact)Female (Neutered)Treatment Details How Long Have You Been Visiting CS Hydro-Physio Ltd? *I am a new clientI am a maintenance clientI am a retuning client/new conditionAre There Any Changes In Your Dogs Overall Health, Lifestyle, Diet or Behaviour In The Past Year? *As a new client to CS Hydro-Physio please complete, if you have not already, our Canine Intake Form. This form can be found in your welcome email, in the owner's zone or, by clicking this link. Describe Briefly Why Your Dog Is Coming To See CS Hydro-Physio Ltd *CS Hydro-Physio Has Two Clinics, One In Theale And One In Tilehurst. Which Is Your Preferred Treatment Clinic? *Tilehurst (249 Overdown Road, Reading, Berkshire, RG31 6NX)Theale (The Oaks, Bottom Lane, Sulhamstead, Reading, RG7 4BA)No PreferenceHow Are You Planning To Travel To Clinic? *CarBusTaxiWalkingOtherThis allows us to ensure we book your dog at the most convenient clinic for you.If You Are Travelling By Car, Are You Happy And Comfortable Getting Your Dog In And Out Of The Car And Into Clinic? *Yes, I am able to get my dog out of the car on my own safelyNo, I would like assistance getting my dog out of the carWe are able to assist at our end as needed, so this just helps us plan for your dogs sessionInsurance InformationIs Your Dog Insured? *YesNoIf no, please leave the rest of this section blank Are You Currently Claiming or Looking To Claim On Insurance For Your Dogs Treatment? *YesNoUncertainIf you are unsure we can discuss this further during your intro session.Policy Provider *Please choose one from list or select other AdmiralAnimal Friends InsuranceArgos Pet InsuranceBought By Many Pet InsuranceCo-op Pet InsuranceDirectlineE & L Pet InsuranceJohn Lewis Pet InsuranceKennel ClubLV= Pet InsuranceMany PetsMiPet CoverMore ThanNFU MutualPerfect Pet InsurancePet ProtectPET-IDPetplanPetwisePuffin InsurancePurely PetsTesco Pet InsuranceWaggelSainsbury's Pet Insurance4PawsOther (if other, please specify below)Policy Provider (other) *Policy Number *Owner Information Owner Name *FirstLastOwner Email Address *Owner Phone Number *Owners Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeVeterinary Information Local Vets NameFirstLastLocal Veterinary Practice *Please choose one from list or select other Castle Vets Pet Healthcare Centre (1 Tilehurst Road, Reading)Companion Care (Inside Pets at Home, Unit 1, GazelleClose, Winnersh. RG41 5HH)Donnington Grove Vet Group (Oxford Road, Newbury)Easiepetcare (106 Crochamwell Road, Reading)Eastcott Referrals (Edison Park, Dorcan, Swindon, SW3 3FR)Eastcott Referrals (Edison Park.Dorwan Way, Swindon)Goring Veterinary Centre (17c High Street, Goring, Reading. RG8 9AR)Henley Vets (The Veterinary Centre) (271 Reading Road, Henley-on-thames)Larkmead Veterinary Group (Ilges Lane, Cholsey, Oxfordshire, OX10 9PA)Medivets Lower Earley (6 Elm Lane, Lower Earley, Reading, Berkshire. RG6 5UF)Mildway Vets (Easton Lane, Winchester, Hampshire. SO23 7RU)Mulberry House (302 London Road, Wokingham, RG40 1RD)Oakley Vets (65 Oakley Road, Caversham)Pines Veterinary Clinic (146a Bath Road, Maidenhead. SL6 4LB)Shinfield Vets (Alstonby, Shinefield Road, Reading, Berkshire. RG2 9BE)Summerleaze Veterinary Hospital (9 Summerleaze Road, Maidenhead. SL6 8EW)The Veterinary Centre (Twycombe Lodge, 1 Loddon Hall Road, Twyford. RG10 9ZA)Tilehurst Veterinary Centre (19 School Road, Tilehurst, Reading, Berks)The Veterinary Hospital (Hungerford) (4a Bath Road, Hungerford, Berkshire, RG17 0HE4a Bath Road, Hungerford, Berkshire, RG17 0HE)Valley Veterinary Group (Pangbourne) (Horseshoe Close, Pangbourne, Berkshire)Valley Veterinary Group (Tutts Clump) (Tutts Clump, Bradfield, Reading, Berkshire.)Vet4Pets (15 Binnel Retail Park)Vets4Pets (Inside Pets at home, Reading Retail PArk, Oxford Road, Tilehurst, Reading, Berkshire. RG30)Vets4Pets (Companion Care) (Rose Kiln Lane, Reading. RG2 0HS)Walpole and Bingham (Wolverhampton)Other (if other, please give details below)Local Veterinary Practice Name *Local Veterinary Practice Telephone Number *Local Veterinary Practice Email Address *Local Veterinary Practice Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeHave You Been Referred To Another Vet Or Specialist Referral Centre *YesNoCondition Referred To Specialist For? *Specialist Referral Vets Name *FirstLastSpecialist Referral Centre *Please choose one from list or select other Dick Whites Referrals (Station Farm London Road Six Mile Bottom Cambridgeshire CB8 0UH)Fitzpatrick Referrals (Halfway Lane Eashing Surrey GU7 2QQ)Hamilton Specialist Referrals ( Cressex Business Park Unit 1 & Unit 5, Halifax Road High Wycombe Buckinghamshire HP12 3SD)Anderson Moores (The Granary, Bunstead Barns, Poles Lane, Hursley, Winchester, Hampshire, SO21 2LL)Lumbry Park (Lumbry Park Veterinary Specialists, Selborne Road, Alton, Hampshire GU34 3HL)The Ralph Veterinary Referral Centre (Fourth Avenue Globe Business Park Marlow Buckinghamshire SL7 1YG)Other (if other please specify below)Specialist Referral Centre Name *Owner Consent To Contact Vets *I hereby give CS Hydro-Physio Ltd permission to contact my local/referring vet to discuss my dog's condition and gain consent for complete treatment.Terms, Condition's & Disclaimers Please Follow This Link and Carefully Read and Agree To The CS Hydro-physio Ltd terms and Conditions for Treatment. Please Read Carefully and Agree To The CS Hydro-physio Ltd terms and Conditions for Treatment as linked above. *I declare that I have read and fully understand and accept CS Hydro-physio terms and conditions.Nuts in Clinic - We occasionally use dog safe peanut butter in our clinics for some dogs. Do you or anyone in your household/immediate circle have a nut allergy that we need to be aware of? *No one in my immediate household has a nut allergy, and I understand that the CS Hydro-physio Clinics are not a nut-free zone.Yes, a member(s) of my immediate household has a nut allergy. I understand that the CS Hydro-physio Clinics are not a nut-free zone, and a discussion will be necessary to ensure safety during my dog's session.History of Seizures - We use a dog safe muscle and joint relief gel on some dogs in clinic. This product contains Wintergreen which has been linked to seizures in some cases. Do you, your dog(s) or anyone in your immediate circle have any seizure disorders that we need to be aware of? *No, I can confirm that neither my dog(s) nor anyone in my immediate circle has any seizure related disorders.Yes, there are seizure related disorders present either in my dog(s) or in my immediate circle.At CS Hydro-physio, we take pride in the quality of service and care we deliver, as well as the achievements of our dogs. We occasionally share these accomplishments on social media platforms, emails, and our website. CS Hydro-physio reserves the right to use video footage and take photographs during sessions for promotional purposes. Please indicate your authorization for each media platform you are comfortable with. *All PlatformsFacebookInstagramEmail (CS Hydro-physio Monthly Newsletter)CS Hydro-physio WebsiteNone Of The AboveOwner Consent To Treat *I, the owner of the above name dog, consent to the treatment of said dog and agree with CS Hydro & Physiotherapy recommendatationSignature * Clear Signature Date of Signature *Data Agreement *I agree and understand that both my personal data and my dog's health information will be stored in a GDPR-compliant manner. This information will be used to contact me regarding my dog's treatment plan, monitor their progress, and improve their care. I understand that no information will be shared with any third parties.Submit
