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 - Horses

Owner’s Details
Name Address Post Code Tel. No. Email
		Mobile No:
Horses’s Details
Name	Sex		Is Horse Insured	Y/N
Breed	Age		Insurance Company
Colour			Policy Number
Veterinary Details (These MUST be completed and signed by the horse’s Veterinary Surgeon)
Veterinary Surgeon
Practice Address
Tel. No.
Description of the horse’s injury/condition, areas of concern, comments etc.,
Is the horse on any Medication, if so what:
In your opinion, is the horse named above in a suitable state of health to undergo Physiotherapy Treatment Yes / No * * Delete as applicable Signature………………………………………… Date ……./…….../…….
I/We declare that I/we am/are the legal owner (s) of the above named horse, 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………/…………/………….