New Client Info at Oklahoma Veterinary Rehabilitation

Name(Required)

First Last

Spouse/Partner Name

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Best email for communications(Required)

Phone(Required)

How would you prefer to be contacted:

Phone

Text

How did you find out about Oklahoma Veterinary Rehabiliation?

Referral from my veterinarian.

Referral from a friend/family member/acquaintance.

Found on the internet (Google search, Facebook/Instragram, etc)

Please list your vet's name.

Whom may we thank?

From which veterinary clinics can we request medical records?

Do you have a primary veterinarian who we can share medical records with (if different from above)?

Do you have pet insurance?

Yes

If yes, with which company?

Is this condition covered?

Pet’s name(Required)

Pet’s breed

Pet’s date of birth (or approximate age)

Gender

Male

Female

Spayed or neutered?

Yes

Species

Weight

Please provide us with some preferred days/times for appointments

Time

Choose a time between 8:30AM-3:30PM Mon/Weds/Thurs, and 8:30AM-5:00PM Tues

Time

Choose a time between 8:30AM-3:30PM Mon/Weds/Thurs, and 8:30AM-5:00PM Tues

What is the primary concern or injury you are seeking evaluation and treatment for?

What diagnostics have been performed (x-rays, bloodwork, CT or MRI, ultrasound) for this issue? Where were they performed?

How long has your pet been dealing with this condition? Is the condition getting better, worse or stable? Please describe how the condition began and it's progression.

What interventions have been helpful in treating this condition? Which interventions have been unhelpful?

How painful do you perceive your pet’s condition to be, on a scale of 0-10? What are the signs of pain your pet shows (i.e. crying, limping, biting, difficulty getting up and around)?

Does your pet have any previous or concurrent health issues?

What is your pet’s current activity level? How has your pet’s condition impacted it’s prior activity level? Does your pet currently require any assistance to perform normal daily activities, such as walking (on slick floors or even on surfaces with more traction?), getting up or down, getting into or out of the car, positioning to urinate or defecte, etc? Please describe any of these limitations.

How has this condition impacted your pet’s quality of life (i.e. mood, appetite, sleep patterns, playfulness, interaction with family and housemates)?

Please provide a detailed list of your pets medications and supplements, including frequency, dosing, and how long they have been taking the medication (i.e. carprofen 25mg twice daily for the last 3 weeks).

Please provide a detailed list of your pet’s diet, including any treats or other foods.

The treatment plan framework provided for your pet is guided by your input, as we work together as a team. It is important to know what your vision for medical care is, so that we can make a plan that will work best for your family.

Often our treatment plans involve some home-care (exercises, etc) – how much time per week do you have to work with your pet?

The finances of veterinary care can sometimes be a source of stress for pet owners. This is an aspect of care that is best to discuss openly and honestly at the beginning, so that we can figure out the best plan together. Does budget play a significant role in your treatment decisions, and if so, do you have a weekly or monthly budget to guide planning?

What are your goals for your pet? Are there certain activities your pet needs to be able to return to doing?

Is there anything else you would like us to know about your pet (i.e., food or medication allergies, fears, loves/preferences, commands, tendency to bite, what motivates your pet, etc)?

Are you ok with us using photos/videos for social media, the website, etc?(Required)

Yes

Provide signature in box as consent to treat(Required)

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