New Patient Questionnaire * Required field Client & Patient Info Client* Patient* Patient Breed* Patient DOB (yyyy-mm-dd) Patient Sex* —Please choose an option—Male( neutered)Male (unneutered)Female (spayed)Female (unspayed) Patient Colour* Insurance Details Do you have pet insurance? If so, please provide us with information including the company and your policy number. Company Name: Policy Number: Contact Info & Address Email* Cell Phone* Home Phone Street* City/Town* Province* Postal Code* Vet Details Regular Veterinarian Name* Clinic Name* Referral Veterinarian* Has your dog been to any other clinics and if yes please give details?* Please be aware that your veterinarian may call you to grant us permission when receiving your pet’s files. Granted permissions allows us to be prepared to receive you. What problem(s) is your pet experiencing (e.g. diagnosis and symptoms)?* Does your pet have any other health problems or allergies that we should be aware of?* What outcome are you hoping to achieve through physical rehabilitation? * List any particular treatments you would like to know more about? How did you hear about us?* Initial Assessment/Cancellation/No Show Policy* Please be aware that to secure your spot for an initial assessment, we do require the payment in full at the time of the booking. Your pet’s health and wellbeing matter to us. To ensure that all our patients are treated fairly and can receive treatment in a timely manner, we ask for a minimum of 3 business days notice for cancellations. Without the required notice or in case of a no show, a fee for the full cost of the scheduled appointment will be charged. Thank you for your understanding and consideration. I have read and agree to the above terms and conditions regarding the policy of Canine Aquafitness. Please prove you are human. Which is bigger, 2 or 8?
