Springfield Farm
Old Parkbury Lane
St Albans
AL2 2DY
Tel: 07957 167 824

 Quincy's

This form must be completed every 2 months by the customers vet or after every 10 swims**

 

Legal owner of the dog (details)

Name(print)

Address(including post code)

 

Telephone number

 

 

 

          Home

Work

Mobile

                                       

Dog’s details

Name

Colour
        Breed

 

                                  Sex

                                   Age

 

            Vaccination expiry                         
                                  date

 

 

 

 

 

Veterinary details (must be completed and signed by the veterinary surgeon)

Veterinary surgeon

Practice

 

Address and telephone no.

 

 

 

 

Details of any Veterinary treatment or surgical procedure undertaken that would prohibit the dog from hydrotherapy.

 

Any areas of concern or caution that needs to be taken when dealing with this dog (any history of people or animal aggression)

 

 

Has the Dog EVER suffered from any Heart problems

 

Does the dog suffer from or ever suffered from Epileptiform fits

 

Dog’s condition & Reason for Hydrotherapy swimming (summary)

________________________________________________________________________________
________________________________________________________________________________

 

Details of any medication which may effect hydrotherapy treatment.

 

 

 

I my opinion, I believe that the above dog is in a suitable overall state of health to undertake hydrotherapy treatment.

 

Signed………………………………………………(Veterinary Surgeon)         Date………../………./…………