TCVM Intake Form

Client Information

Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Email

Today's Date

Mobile Phone

Home Phone

Work Phone

Other Guardian Name

First Last

Pet Information

Pet Name*

First Name

Breed*

Date of Birth (if unknown, see next question)

If the DOB is unknown, what is your pet's estimated age?

Family Veterinarian Name*

Clinic Name*

Rabies/Distemper Expiration

Sex*

Male
Female

Spay/Neuter*

Yes
No

Current Health Information

Does your dog have any condition that we should be aware of such as recent surgery, injuries, treatment, been sick lately or have a need for daily medication?*

Yes
No

Details

Has your dog harmed any person or shown aggressive behavior towards any person or any other dog?*

Yes
No

Details

Consent*

I agree to the swim and play rules.

Swim & Play Rules can be found at http://dog-swim.com/wp-content/uploads/2020/11/CRCG_SwimPlayRules.pdf

How did you hear about us?*

Friend
Vet
Other Dog Healthcare Provider
Promotion
Web search
Advertising
Other

Details

Do we have your permission to add you to our CRCG newsletter mailing list?*

Yes
No

ie: Monthly specials, Holiday theme parties, fundraisers, contests, game days, etc. (Note: CRCG does not share or sell your contact information. All information is confidential.)

How would you like to be contacted with appointment reminders?*

Additional Pets

Do you have any additional pets?

Pet Name

First Name

Breed

Date of Birth

Sex

Male
Female

Spay/Neuter

Yes
No

Rabies/Distemper Vaccination Expiration Date

What brings you to CRCG?*

Rehabilitation
Recreational Swimming

My dog is healthy and not under treatment at this time.*

Yes
No

Details

Please note if this dog is under any treatment provided by a vet or if there are health problems or concerns of which you would like us to be aware.

Liability Agreement

Please select the checkboxes to indicate you have read and understood the information provided.

I understand and agree that in admitting my dog to the use of its facility, CRCG has relied on my representation that my dog is in good health or I have disclosed any known health issues.

I have documented any issues in the past of harm, aggression or threatening behavior towards any person or any other dog.

I understand and agree that the staff of CRCG is not engaged in the practice of general veterinary medicine.

I understand and agree that CRCG, its staff and volunteers, will not be liable for any problems that arise out of my or my dog’s use of CRCG’s facilities and I hereby release them from liability of any kind whatsoever in regards to my dog(s) attendance and participation at CRCG.

I understand that I am solely responsible for any harm caused by my dog(s) while my dog is utilizing the facilities of CRCG. This includes any harm to persons and/or other dogs as well as to the physical property of CRCG.

I understand and agree that any problems that develop with my dog will be treated as deemed best by the staff and volunteers of CRCG, in their sole discretion. I assume full financial responsibility for any and all and all expenses involved including injuries to persons and/or dogs, and damages to the facility.

I understand that if an injury caused by my dog or to my dog will only be treated if it is considered to be of a serious nature as determined by CRCG staff in its sole discretion. In the event that treatment is administered, I accept full responsibility for financial obligation of treatment to my dog and any dog injured as a result of my dog’s behavior.

I understand that I am responsible for paying 100% of the cost of a scheduled appointment if I cancel with less than 24 hour notice.

Package refund requests will be calculated by charging the full price for the services used.

I have reviewed and selected the above conditions of the liability agreement. CRCG will be unable to treat my pet if the liability agreement is not completed prior to my first appointment.*

Yes

Photo Release

I grant to CRCG, its representatives and employees the right to take photographs of me and my dog in connection with any CRCG services. I authorize CRCG, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that CRCG may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.*

Yes
No

CRCG Recreational Pool Policy

CRCG provides fun and safe fitness, conditioning and rehabilitation services. The recreational pool at CRCG is designed for fun swims. The CRCG team cares about the health, safety and welfare of your dog. If your dog has an issue that could contribute to injury while swimming or if your dog is otherwise unable to safely navigate in the recreational pool (this includes incontinence), the CRCG staff will stop the swim and use of the pool will be discontinued until the issue has been resolved. You will be referred to the CRCG rehabilitation services if it is more appropriate for your dog’s condition. You will need a release from a CRCG rehabilitation therapist before returning to the pool if the issue is physical - such as injury, orthopedic or neurological. All rehabilitation clients that are using the recreational pool as part of their rehabilitation plan must follow the treatment plan and requirements for rechecks. The use of the recreational pool will be discontinued if the plan directives are not followed and the recheck requirements are not met.

I agree that there are inherent risks to me associated with use of the CRCG facilities arising out of or associated with use and conditions, such as swimming, wet floors, exercise mats, and other dogs. In consideration for CRCG granting me permission to use these facilities, I agree to release CRCG from liability arising out of or associated with such use, and hereafter waive any and all claims which may arise out of or be associated with such permissive use of the CRCG facilities.*

Owner's Name Date

I certify that I have read and understand this Agreement and that the information set forth above is true and correct. I agree to accept all the terms, conditions, and statements of this agreement, and any rules or regulations of CRCG.

What presenting concern(s) do you have for your pet? Include dates of occurrence(s).*

Has/have the problem(s) progressed, stayed the same, improved or waxed and waned?*

Are there any medical history concerns such as illnesses, surgeries, injuries, or cancer?*

What diagnostics have been performed (radiographs, blood work, ultrasound, MRI, CT, etc)?*

Have any treatments been started or tried such as rehab, laser, acupuncture, or chiropractic therapy?*

What is your pet’s current activity level? Are there any activity restrictions? (Include daily activities such as walks, dog park visits, playing in the yard, etc.).*

What is your pet’s prior activity level before the presenting complaint?*

Please note all medications you currently give your dog. Please bring medication bottles with you to the first appointment if possible. NA if your dog is not currently taking any medications.*

Has your dog ever had a seizure or been diagnosed with heart disease? If yes, please provide dates and details below.*

What is your pet’s diet?*

Does your pet have a good appetite?*

Does your pet have any allergies or food sensitivities?*

Does your pet have any difficulty urinating or defecating?*

Is your pet able to squat or lift leg normally to urinate and defecate?*

Does your pet exhibit any urinary or fecal incontinence? (any accidents without awareness)*

Describe the pain behaviors your pet exhibits. (crying, licking, panting, limping or restlessness)*

Does your pet’s pain or lameness change with weather, exercise, and/or rest? (describe changes)*

On a scale of 0-4, how painful is your pet? (0 = non-painful – 4 = most painful)*

Have there been any changes in your pet’s mood or behavior?*

Describe your pet’s environment. (Type of floors, stairs, furniture they climb on, fenced yard, and/or dog door)*

What are your goals for your pet?*

Comments

This field is for validation purposes and should be left unchanged.