New Patient Information Form To help us best prepare for your pet’s appointment, please complete this form Step 1 of 6 16% Pet Owner DetailsEnquiry TypeThis information is for an existing appointment for my pet at Dogs In MotionI would like to book an appointment for my petI have a product or patient enquiryPlease describe your product or patient enquiryYour 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Your Pet's DetailsNameSpeciesBreedAgeDOB if knownSex Male Female Desexed Yes No Referral to our ClinicWas your pet referred to our clinic? Yes No Who referred your petIf you were not referred by a Vet / Specialist, how did you hear about us? Internet / Google Social Media Word of Mouth I am a previous client If you heard about us through a client of ours, please let us know their name so we can thank them:Vet InformationRegular Vet ClinicReferring Vet Clinic (if different from regular vet)Pet InsuranceDo you have Pet Insurance? Yes No Which Insurance Company is your policy with? Your Pet’s Current ProblemWhat 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 therapiesIs 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 describeDo 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 outWhat 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 HistoryHas your pet had any other injuries, surgeries or conditions affecting their mobility? Please describeIs there any other additional information you think we need to know to help us care for your pet?Vet Instructions and planHas the vet provided you with any specific instructions or plans for next steps of treatment? Please describeGoalsAre 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 HistoryIf 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 Select files Accepted file types: jpg, pdf, doc, docx, mp4, mov, Max. file size: 25 MB, Max. files: 25.