ONLINE CONSULTATION

Australia online comprehensive assessment physiotherapy

Comprehensive Assessment Order Form

Cost: $90 AUD (phone/email/skype)

Important:

  • Once you’ve completed the form below and clicked ‘Submit‘, you 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

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

Important

1 • Press “Send” button (above) to submit the 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 —