ONLINE CONSULTATION

Australia online comprehensive assessment physiotherapy

Comprehensive Assessment Order Form

Cost: $100 AUD (phone/email/skype/facetime)

Important: 

  • Read green panel at base of page

  • Once you’ve completed the form below and clicked ‘Send‘, you can then click “Payment” button, and will be taken to the Payment Page (PayPal/Credit Card or Direct Deposit).

  • You will receive an email with information on how to send us reference photos and/or video.

PLEASE COMPLETE THE FOLLOWING FORM

Use this diagram to locate the region for the first question below

Your Comprehensive Assessment Form:

    Your Full Name *

    Your Email *

    Area on dog that question relates to (use diagram as reference) *

    Preferred contact number (home, work or mobile) *

    Referring Vet

    Referring Vet's Phone number

    Referring Vet's Email address

    Pet Name *

    Species *

    Breed *

    Colour *

    Sex
    FemaleMale

    Weight *

    Age *

    Current history (what has happened more recently to explain what your concerns are with your animal)

    Your comprehensive question *

    Past History (any relevant information regarding previous musculoskeletal problems)

    Exercise Routine – Before Injury: (specifically how long; what terrain e.g beach, hills; on/off lead)

    Exercise Routine – After Injury

    Veterinary Intervention (Including Xrays/Scans/Advice)

    Slippery floor?
    YesNo

    Does your pet like to swim?
    YesNo

    Other pets?
    YesNo

    Pool?
    YesNo

    Is your pet inside/outside?
    YesNo

    Medication

    Supplements

    Any behavioural issues

    Diet (please describe)

    Physiotherapy Goals

    Additional Information

    How will you pay for this assessment? *
    Secure PayPal (Credit Cards accepted)Direct Deposit

    s

    You must click the above 'Send' button BEFORE the "Payment" button, or you'll lose all the form information!

    Important

    1 • Firstly, press “Send” button (above) to send form

    2 Wait for confirmation message!

    3 • Then click “Payment” button below to go to payment page.

    — Do NOT click ‘Payment’ button below before the “Send” button or you’ll lose all the form information —