Rehabilitation Intake Form (Pet Retreat Only)

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Client Information
Referral Information

I understand that an examination may be required by Riverbank veterinarian if my pet is a candidate for rehabilitation prior to starting treatment.

Pet Information

I hereby authorize / do not authorize Riverbark to photograph/obtain video of my pet for use in marketing materials, social media, presentations, educational purposes, etc...  Initial

I hereby authorize the Certified Rehabilitation Therapist (CCRA) to examine, evaluate or treat (under supervision of the CertifiedAttending Veterinarian) the above described pet with any and all therapeutic modalities required for rehabilitation and therapy. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges must be paid at the time of release and that a deposit may be required.

I understand that Riverbark Pet Retreat is a referral clinic and will be maintaining a close referral relationship with my regular veterinarian. I understand that I will not become a veterinary client of Riverbark except where Riverbark offers services my regular veterinarian cannot provide.

I understand there are some inherent risks in working in water and with therapeutic equipment and hold harmless Riverbark Pet Retreat for any injuries while on premises. Should some unexpected life-saving emergency care be required for my pet and the attending veterinarian be unable to reach me? this practice's staff has my permission to provide such treatment and I agree to pay for all related fees.

I understand that an estimate of the costs for rehabilitation services will be provided to me upon my request and that 1 am encouraged to discuss all fees attendant to such care before services are rendered and during this pees ongoing medical treatment.

Financial Information

Form of payment preferred (please circle) Visa / MasterCard / Discover/ Cash / Check / Care Credit

Full payment is required at the time services are provided. I understand that upon my request the hospital staff will provide an estimate of any current and/or anticipated charges. By signing below, I am authorizing veterinary care and/or physical rehabilitation be provided for the pet(s) presented by me or by agent(s). I am the legal owner/agents of this/these pet(s) and as owner/agent I understand that I am financially responsible for all services provided.