Registration Form

Please only fill in this form if you have contacted Laura and booked an appointment. This form provides LMG Veterinary Physiotherapy with information about you and your animal for her records.

Under the Veterinary Surgeons Act 1966 it is a legal requirement for a Veterinary Physiotherapist to obtain Veterinary Consent before an animal receives physiotherapy. The information you input in to this form will be emailed directly to your vet requesting that they give permission for your animal to be seen for physiotherapy.

Please fill this in at least a week before your appointment to give your vet time to respond.

You can download a paper copy of this form here.

Owner Details
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone Number*
Email*
Your Vet's Details
Practice Name*
Practice Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Your Vet's Name
If known
First Last
Your Vet's Phone Number*
Your Vet's Email Address*
Animal Details
Name*
Age*
Species*
- Horse
- Dog
Height*
Sex*
- Gelding
- Mare
- Stallion
Breed*
Sex*
- Dog – neutered
- Dog – unneutered
- Bitch – neutered
- Bitch – unneutered
Is the animal on any regular medication?*
- Yes
- No
Please detail medication below*
What is the reason for your appointment with LMG Veterinary Physiotherapy?*
eg. Maintenance or a specific injury
Does the animal have any pre-existing conditions?*
- Yes
- No
Please detail pre-existing conditions below*
I agree to LMG Veterinary Physiotherapy's Terms & Conditions.*
Please tick – Terms & Conditions can be found here.
I agree that LMG Veterinary Physiotherapy can contact my Veterinary Surgeon and that the above animal's veterinary records can be shared.*
Please tick here

Laura Gibson PGDip MIRVAP

07904 896974

laura@lmgvetphysio.co.uk

Based in Knutsford, Cheshire – covering all of North West England

Terms & Conditions

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Owner Details

Your Vet's Details

Animal Details