Veterinary Consent to Physiotherapy Form

Vet Practice Name

Consenting Vet First Name

Last Name

Phone

Vet Practice Address

Client Details

Name of Client

Name of Horse

Horse Details

Please give details of any past and current Veterinary musculoskeletal history, diagnoses and treatments:

Alternatively, please send the patients history and/or vet reports directly to the owner, or attach below if permission has been given.

If easier, email to; kmvetphysio@gmail.com

Upload History

Or Link URL to history/scans etc.

Please tick if the patients vet report note/s or history has been sent to the owner/carer.

Consent to Physiotherapy Assessment and Treatment

I consent for the above patient to be assessed and treated by Kimberley Mallett at Performance Animal Physiotherapy, as deem appropriate and within their scope of practice, including any electrotherapy treatments.

Add any notes, recommendations or suggested treatment plan if appropriate:

Please detail any ongoing/planned veterinary treatments or medications (NSAIDS, shockwave, injectables etc) which may affect physiotherapy treatments:

Treatment Reports

Physiotherapy session reports will be forwarded after the initial consultation, as well as subsequent updates as deemed appropriate.

Signature or Practice Stamp

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Printed Name

Date

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Veterinary Consent to Physiotherapy Form

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