Owner Referral Form - CS Hydro Physio Ltd

Skip to content

About Us
Hydrotherapy
Physiotherapy
Laser
Testimonials
Owners Zone
Contact Us

About Us
Hydrotherapy
Physiotherapy
Laser
Testimonials
Owners Zone
Contact Us

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.

Pet Details

Layout

Name *

Breed *

Colour *

Age *

Date of Birth (DOB)

Gender & Neutering Status *

Weight (Kg) *

Please estimate if uncertain

Treatment Details

How Long Have You Been Visiting CS Hydro-Physio Ltd? *

I am a new client
I am a maintenance client
I am a retuning client/new condition

What Are The Main 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.

Layout

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 Preference

How Are You Planning To Travel To Clinic? *

This 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 safely
No, I would like assistance getting my dog out of the car

We are able to assist at our end as needed, so this just helps us plan for your dogs session

Insurance Information

Layout

Is Your Dog Insured? *

Yes
No

If no, please leave the rest of this section blank

Are You Currently Claiming or Looking To Claim On Insurance For Your Dogs Treatment? *

Yes
No
Uncertain

If you are unsure we can discuss this further during your intro session.

Policy Provider *

Policy Number *

Provider Phone Number

Owner Information

Layout

Name *

First

Last

Email Address *

Phone Number *

Owners Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Veterinary Information

Layout

Local Vets Name *

First

Last

Local Veterinary Practice Name *

Veterinary Practice Telephone Number *

Veterinary Practice Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Have You Been Referred To A Specialist Referral Centre *

Yes
No

Condition Referred To Specialist For?

Layout (copy)

Specialist Vets Name *

First

Last

Specialist Veterinary Practice Name *

Veterinary Practice Telephone Number *

Veterinary Practice Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Checkboxes *

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 Platforms
Facebook
Instagram
Email (CS Hydro-physio Monthly Newsletter)
CS Hydro-physio Website
None Of The Above

Owner Consent To Treat *

I, the owner of the above name dog, consent to the treatment of said dog and agree with CS Hydro & Physiotherapy recommendatation

Signature *

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.

Useful Links

Our Story
Veterinary Referrals
Owner Zone/Log-In
Hydrotherapy
Physiotherapy
Laser Therapy
Contact Us
Shop
Privacy Policy & More…

Follow us on Facebook

Contact Us

07880 744 225
cshydrophysio@gmail.com
@cshydrophysio

Opening Hours

10:00am – 4:00pm (Monday – Saturday)
Closed (Sunday)
*Appointments outside of these hours may be arranged on an individual basis. Please contact us to discuss this further.

Copyright © 2024 CS Hydro Physio Ltd | Powered by Astra WordPress Theme

Website Design & SEO by AP Services

Scroll to Top