Physical Rehabilitation Consultation Submitter Email*Please enter the email address of the user submitting this form. Enter Email Confirm Email Patient Name First Last Case Number Date MM slash DD slash YYYY Breed Sex Male Female Age Weight Requesting Service Requesting DVM Presenting Complaint Diagnosis Surgery Surgery Date MM slash DD slash YYYY Brief history of Current Condition or additional medical conditionsAdditional Medical Conditions:Current MedicationsPlease list current medicationsMedication 1Medication 2Medication 3 Bladder/Bowel Continence Yes No Ambulatory Yes No Will Bite Yes No History of Cancer Yes No If (Yes) explainPlease explain if you answer yes to any questions. Restrictions (catheter, incision, movement, etc.)Underwater Treadmill Yes No Patient status In-patient Out-patient To Go Home Time : Hours Minutes AM PM Reason for Consultation
