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Rehab Registration Form

In order to streamline your visit with our rehabilitation team, please fill out the form below prior to your pet’s first visit with us!

CLIENT INFORMATION

Name *

First

Last

Email *

PET INFORMATION

Medical History

Patient's Name *

Briefly, please tell us why we are seeing your pet today

Has your pet been previously evaluated for this problem?

No
Yes

By whom and when?

Have any diagnostic tests been performed?

No
Yes

Which ones?

Have any treatments (medications, rehab therapy, acupuncture, etc) been started?

No
Yes

Which ones?

Has your pet’s current medical

Improved
Worsened
Stayed about the same?

Current Medications/Supplements:

Please note the dosage, frequency, last time given and if refills are needed.

Previous orthopedic injuries/surgeries/pertinent medical history

Does your pet have adverse reactions to any medications?

No
Yes

Which ones?

Does your pet have dietary restrictions/food allergies?

No
Yes

Which ones?

Does your pet have full control of its bowels?

No
Yes

Does your pet have full control of its bladder?

No
Yes

ACTIVITY LEVEL

Check All That Apply

PREVIOUS activity (prior to current medical condition):

Sedentary (out to eliminate only)
Easy walks
Moderate walks
Rigorous walks
On leash
Off leash
In-home/backyard play
Day care, rough play with other dogs
Working
Competition

Average walk time

Average amount of walks per day

Occupation

Sport

CURRENT activity:

Sedentary (out to eliminate only)
Easy walks
Moderate walks
Rigorous walks
On leash
Off leash
In-home/backyard play
Day care, rough play with other dogs
Working
Competition

Average walk time

Average amount of walks per day

Occupation

Sport

CURRENT RESTRICTIONS

Confined to cage/crate/small space

Yes
No

Owner-imposed
Patient-imposed

From off-leash activity

Yes
No

Owner-imposed
Patient-imposed

From play

Yes
No

Owner-imposed
Patient-imposed

From stairs

Yes
No

Owner-imposed
Patient-imposed

From furniture

Yes
No
My pet is not allowed on furniture

Owner-imposed
Patient-imposed

Other

HOME LIFE

Flooring

Hardwood
Tile
Carpet
Linoleum
Other

Other

Stairs

In/out of house
Flights inside the house
None

In/out of house #

Flights inside the house #

Other Pets

No
Yes, but they don’t play
Yes, and they love to play

Species, age, breed

GOALS

What are your pet’s rehab-specific goals (ex: walk without assistance, off-leash play, back to normal activity)?

Are you interested in a formalized Rehab program?

No thanks, but I’d love some home exercises.
Let’s see what the Dr says.

Are we allowed to post photos of your pet(s) on social media or for use them for advertising purposes? *

Yes
No

Is there anything else you feel is important for the Rehab Team to know?

Rehab Client Expectations and Consent Form

Contact Maine Veterinary Medical Center

Get in touch!



Address

1500 Technology Way
Scarborough, ME 04074



Phone



Email

reception@mvmc.vet



Hours

Open 24/7

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