VCA SouthPaws Veterinary

Specialists & Emergency Center

8500 Arlington Blvd

Fairfax, VA 22031

703-752-9100

Consent for Rehabilitation Services

I, the undersigned owner or owner agent of the pet identified above, certify that I am over the age of 18 years of age. I hereby consent to my pet participating in rehabilitation at one of the above facilities with Pet Rehab or within my home.

All pets will be evaluated and treated according to their diagnosis and evidence based protocols. Treatments may include ultrasound, electrical stimulation, massage, heat /ice, range of motion exercises, therapeutic exercises, agility training, aquatic therapy, as well as strength and endurance training. A home exercise program will be designed and provided as appropriate for your pets’ individual needs.

All treatments are done by referral and in collaboration with a qualified veterinarian; Pet Rehab designs the specific rehabilitation and exercise program for your pet. Pet Rehab will provide ongoing consultation with the referring veterinarian.

While I accept that all procedures will be done to the best of the abilities of the staff of Pet Rehab, I certify to no guarantee or warranty has been made regarding the results that may be achieved. I fully release Pet Rehab, its officers, directors, owners, employees, agents, contractors, representatives, successors, assignees, and affiliates from, and will indemnify and hold them harmless from and against, all liability for any injury, expense and or damage whatsoever arising out of, related to or in connection with my pet’s physical therapy with Pet Rehab.

Fees for Service:

I agree to pay Pet Rehab for rehabilitation services as rendered at the following rates:

Initial Evaluation:   $220.00 in clinic, $200 zoom,  Follow-up visits:  $120.00 in clinic, $100 zoom each

**** Cancellations require 24 hours notice, otherwise, a NO SHOW FEE is $50.00 each ****

Payment Types: Cash, Checks or Venmo payment. Pet Rehab does NOT accept credit card payments at this time.

Other Helpful Information

The following questions are to help make your pets visit with Pet Rehab positive and safe. We want to promote a healthy and happy rehabilitation experience. An individualized treatment protocol will be designed that is best suited for your pets’ needs to allow for the fullest recovery and/or return to a normal level of activity. Owners will be educated in precautions and environmental safety concerns as needed.

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Owner’s Name *

First

Last

Address *

Home Phone *

Cell Phone *

Work Phone *

Email Address *

Referring Veterinarian / Facility

Primary Veterinarian / Facility

Reason for Referral *

Patient Name *

Patient Information

Breed *

Patient Information

Edad

Selected Value: 1

Patient Information

Male / Female *

• Male
• Female

Patient Information

Spayed / Neutered *

• Yes
• No

Patient Information

Rabies vaccination *

• Yes
• No

Patient Information

Family Environment: (other pets, children):

Other Helpful Information

Home Environment: (stairs, fenced yard, hardwood/tile floors, food/water dishes on floor, etc.):

Other Helpful Information

Allergies:

Other Helpful Information

Special Diet / Food Restrictions:

Other Helpful Information

Behavior Issues: (aggressive, biter, territorial, doesn’t like other dogs/ cats, doesn’t like paws touched, etc.)

Other Helpful Information

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Pet Rehab  * 11721 Sugarland Road, Herndon, VA 20170  *  571-213-2624  *  703-444-9735 (F)