New Patient Information Form

Pet Owner Details

Enquiry Type

Please describe your product or patient enquiry

Your Name(Required)

First Last

Your Phone(Required)

Your Email Address(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Pet's Details

Name

Species

Breed

Age

DOB if known

Sex

Male

Female

Desexed

Yes

No

Referral to our Clinic

Was your pet referred to our clinic?

Yes

No

Who referred your pet

Vet Information

Regular Vet Clinic

Referring Vet Clinic (if different from regular vet)

Pet Insurance

Do you have Pet Insurance?

Yes

No

Which Insurance Company is your policy with?

Your Pet’s Current Problem

What is the main problem your pet is experiencing that you would like Dogs In Motion to help you with?

When did this problem start?

How has your pet been since the issue started?

Worse

Same

Better

Please describe:

Has your pet had other treatment - veterinary or other therapies for this problem?

Yes

No

Please describe other treatments or therapies

Is your pet currently on any medication or supplements?

Yes

No

Please list medication and or supplements

Your Pet’s Current Ability & Mobility (what your pet can do since this problem started)

How much exercise does your dog currently do each day? On or off leash?

Has the vet recommended any exercise restriction? Please describe

Do you use any equipment or harnesses to help your pet get up or walk?

How does your pet spend their day between exercise sessions? E.g. indoors, outdoors, confined in a crate, free to move in and out

What type of floor covering do you have in the area your pet spends their time and how do they manage on this surface? Are they steady on their feet?

Do you have stairs at home and is your pet using these at present?

Does your pet currently get on the furniture and do they need assistance to do so?

Where does your pet sleep and on what type of bedding?

Is your pet having any accidents or difficulty toileting e.g. holding the position to toilet?

Your Pet’s Previous Exercise (what your pet did before this problem started)

What was your pet’s regular exercise routine? e.g. on and off leash exercise, ball, sport, playing with other dogs (at home or at the park) Please describe how many days per week and approximate time during each activity

Your Pet’s Past Medical History

Has your pet had any other injuries, surgeries or conditions affecting their mobility? Please describe

Is there any other additional information you think we need to know to help us care for your pet?

Vet Instructions and plan

Has the vet provided you with any specific instructions or plans for next steps of treatment? Please describe

Goals

Are you looking for an appointment with one of our team members?

Yes

No

What are the goals you have for your pet? What would you like us to help you most with?

Images, Videos, Vet History

If you have any images or video’s of your dog walking, or demonstrating their current mobility issues, or any veterinary history you have available please upload here - NOT COMPULSARY Upload your files in .mov . mp4 .jpg .pdf, .doc or .docx format

Drop files here or

Accepted file types: jpg, pdf, doc, docx, mp4, mov, Max. file size: 25 MB, Max. files: 25.