Rehab Form

This questionnaire is provided so that we gain a more comprehensive overview of your pet’s condition.

Date *

Owner's First Name *

Owner's Last Name *

Pet's Name *

Phone *

Email *

Current diet *

Favorite treats *

Allergies *

Rabies Vaccine Due Date - Rabies vaccine must be up to date by initial consult exam *

Current medications and supplements (please include dose and frequency) *

Referring Veterinarian *

Referring Hospital *

Presenting complaint *

When was the problem first noticed *

Your pet’s brief medical history (illnesses, injuries) – please include dates *

Previous diagnostics performed (CT, MRI, X-rays, bloodwork, ultrasound)

Previous treatments and/or surgeries and dates – please include alternate modalities (chiropractic, acupuncture, etc)

Your pet’s activity

Prior to presenting complaint *

Current daily activities (walks, dog parks, backyard): *

Pain level on a scale of 0-4 (0-non painful, 4-most painful) *

What pain behaviors do you notice (licking, panting, limping) *

What is your rehab goal for your pet *

How did you hear about our rehab program?

Friends/Family

Referred by Vet/Specialist

Social Media

Other

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By submitting this form I acknowledge and agree that Dr. Kristi Wubben is my pet’s rehabilitation specialist veterinarian and not their primary physician. Thus Dr. Wubben is not responsible for the medical needs of my pet outside of their specific rehabilitation noted in their record from the initial consult.

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Hours

Open 6 Days a Week

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Monday:08:00 am - 05:30 pm
Tuesday:08:00 am - 05:30 pm
Wednesday:08:00 am - 05:30 pm
Thursday:08:00 am - 05:30 pm
Friday:08:00 am - 05:30 pm
Saturday:08:00 am - 03:00 pm
Sunday:Closed

Rehab Form

Rehab Form

Your pet’s activity

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