Veterinary Pre-appointment Consent form

In order to ensure that your animal receives the best care I require the below consent form to be completed by the treating vet to ensure I have an accurate history/ diagnosis, and for legality. The form can be found below. Alternatively, please contact me and I can send you a copy of the form to fill out.

Thank you for your support and referrals.

Carers Name and Address

Contact Number

Animal Species, Name, Breed and Age

Reason for the Referral

Any Relevant Medical History, Medications or Underlying Reasons that the animal's ability to exercise may be affected

Insurance Details if relevant

I recommend/consent this animal attends for assessment and any appropriate physiotherapy treatment / exercise programme given by Ellen Goldsmith. I understand, in making this referral, I am not responsible for any physiotherapy assessment, treatment or exercise programme given and the provision of professional indemnity insurance is the responsibility of Ellen Goldsmith. Completion of the authorisation details below and submission of this form is my electronic signature

I agree

Authorised by (to include Vet Name, Address, Email address and Contact number)