Pet Hydrotherapy Intake Form
Please share your pet’s details, medical background, and session preferences so the clinic can prepare for hydrotherapy safely and appropriately.
Owner & Pet Information
Owner Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Pet Name
*
Pet Species
*
Please Select
Dog
Cat
Rabbit
Bird
Horse
Other
Breed
Age (Years)
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
Male
Female
Unknown
Weight (lbs)
*
Hydrotherapy Need & Medical Background
Main goal of therapy
*
Pain relief
Mobility improvement
Rehabilitation after surgery
Rehabilitation after injury
Weight management
Conditioning
Improved balance or coordination
Other
Reason for hydrotherapy
*
Primary concern or diagnosis
Referring veterinarian or clinic name
Recent surgery or injury details
Current medications
Known allergies
Mobility limitations and relevant medical conditions
Session Readiness & Safety
Can the pet swim?
*
Yes
No
Not sure
Is the pet fearful or anxious around water or handling?
*
Yes
No
Sometimes
Behavior concerns
Bites
Nips
Scratches
Jumps on people
Pulls on leash
Aggressive toward other animals
Sensitive when touched
Startled by loud sounds
Other
Has the pet had hydrotherapy before?
*
Yes
No
Not sure
Special handling instructions and safety notes
Scheduling & Preferences
Preferred Appointment
Preferred Session Type
Please Select
Underwater Treadmill
Pool Therapy
Land-Based Rehab
Initial Evaluation
Other
Preferred Therapist or Staff Member
Please Select
Any Available
Alex
Jordan
Taylor
Other
First Visit Notes
Submit Intake
Should be Empty: