Rehabilitation Forms

Complete rehabilitation forms for Vanguard Veterinary Hospital in West End, NC before your pet’s rehab, mobility, recovery, or pain management visit. These forms help our team understand your dog or cat’s condition, goals, comfort level, and medical history.

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Rehabilitation Consent Forms

Please complete this form when referring a patient for rehabilitation, pain management, mobility support, or recovery care.

Signature Owner

Welcome to Vanguard Veterinary Hospital’s Rehabilitation, Sports Medicine, and Pain Management Program. We pride ourselves on providing a comprehensive program customized to the needs of your pet’s health and mobility. Regardless of what brings you and your pet to us, we are thankful for your commitment to your pet in pursuing the next step in veterinary care.

After this consultation, if you decide to pursue treatment at Vanguard, we ask that you be aware of some of the following information:

1. We will be providing updates to your primary veterinarian as your pet progresses 1) at Vanguard. As a rehabilitation referral center, we will be focusing specifically on the pain and/or myofascial and musculoskeletal health of your pet, we ask that medical concerns unrelated to rehabilitation be addressed by your primary veterinarian. If your primary veterinary hospital is Vanguard, we ask that a separate appointment/time be set up on the medical side to address the problem.

2) We will be addressing nutritional health, as well as the use of certain health supplements, during the rehabilitation and pain management program. Please bring us a list of current foods and treats, as well as the quantity being fed.

3) If your pet has an ongoing medical issue or if they are on any prescribed medications, please let us know as these can affect our techniques and the outcome of our treatments.

4) For weight loss and conditioning programs, we may request a letter/referral from your primary veterinarian stating that they believe your pet is healthy enough to start a conditioning program at Vanguard.

5) We do send “homework” home with owners so that they can participate in the rehabilitation program so that we get the most out of your time in the hospital. If something prohibits your ability to perform any technique at home, please let my staff know.

At this consultation, you will be shown the therapeutic level your pet will be started on and the fee schedule for this plan. For future appointments we will bring your pet in unaccompanied but please be prepared to wait for approximately an hour while we complete the session. The appointment may be the first therapy session or an assessment exam where we will be taking measurements, thermal imaging, and more analytics to determine the baseline or start point of your pet. We will periodically repeat these diagnostic tests to determine progression, as well as to report back to your primary veterinarian and your surgeon, if applicable. After the assessment exam, your pet will officially start their designated program and we will set up appointments based on your availability!

Dana A. Vamvakias, DVM, CCRT, cVMA, CAC, CVPP

Owner Signature

Clear Signature

Alternative/Rehabilitation Therapy Consent

Client’s Name *

Patient’s Name *

I hereby certify that I am the owner or an authorized agent of the owner and I am over the age of eighteen.

Alternative/Rehabilitation therapies, which may be used may include any of the following: Acupuncture, Piezowave (Shockwave) Therapy, Chiropractic, Laser Therapy, Electrical Stimulation, Hydrotherapy, Physiotherapy, Manual Therapy, Electromagnetic Field Pulse Bed

I agree to the use of these therapies with the understanding that they may aid in the treatment of my pet's condition.

I have been informed about these alternative/rehabilitation therapy procedures, with satisfactory explanation, including the purpose for performing them and the risks involved. I realize that there can be no guarantee regarding the outcome of these procedures. I have been encouraged to ask questions and agree not to proceed with these alternative veterinary diagnostic procedures until I have them answered to my satisfaction.

authorized Vanguard

hereby consent to the provision of the above alternative/rehabilitation therapy or therapies provided by the attending doctor(s) and staff at this facility. In the absence of negligence, agree to hold them harmless for the absence of response to treatment or any ill effects experienced by my pet.

I will follow up with my primary care veterinarian for any routine and/or health concerns that may arise while under Vanguard Veterinary Hospital's care for therapy.

I will follow up with my primary care veterinarian for any routine and/or health concerns that may arise while under Vanguard Veterinary Hospital's care for therapy.

I hereby consent to allowing my pet's images/videos to be shared on Vanguard Veterinary Hospital's website, social media and/or printed materials?

Accept
Decline

Payment is due at the time of service for individual sessions or at the start of package sessions. In the event the owner/patient is unable, unwilling, or other unforeseen circumstances arise that treatment can not/will not continue, any unused portions of individual and/or packages are non-refundable and expire after 12 months.

Cancellation policy: In the event that an appointment needs to be cancelled we ask for a 24 hour notice. If a 24 hour notice can not be provided client may be charged for that appointment.

Email Address *

Signature of Owner or Authorized Agent *

Clear Signature

Date

Signature of Witness

Clear Signature

Date

Rehabilitation Forms

Rehabilitation Intake Form

Diet & Appetite

Rehabilitation Consent Forms

Alternative/Rehabilitation Therapy Consent

Canine Chronice Pain Score Index

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