Hydrotherapy for Dogs - Physiotherapy for Dogs & Horses

5 Hackett Drive – Smethwick – West Midlands B66 1NX

Tel: 0121 558 5020 – Fax: 0870 0522069 – Email: enquiries@woofnwater.co.uk – www.woofnwater.co.uk

Client Referral Form - Dogs

Owner’s Details
Name Address Post Code Tel. No. Email
		Mobile No:
Dog’s Details
Name	Sex		Is Dog Insured	Y/N
Breed	Date of Birth		Insurance Company
Colour	Vac. Expiry Date		Policy Number
Veterinary Details (These MUST be completed and signed by the dog’s Veterinary Surgeon)
Veterinary Surgeon
Practice Address
Tel. No.
Description of the dog’s injury/condition, areas of concern, comments etc.,
Is the dog on any Medication, if so what:
In your opinion, is the dog named above in a suitable state of health to undergo Physiotherapy and/or Hydrotherapy Treatment Yes / No * * Delete as applicable Signature………………………………………… Date ……./…….../…….
I/We declare that I/we am/are the legal owner (s) of the above named dog, and that the information given on this form is correct. I/We have read and fully accept the Terms and Conditions set out by Woof ‘n’ Water. Signature(s)………………………………………….. Date………/…………/………….