Physical Rehabilitation Registration

Thank you for your interest in Canine Physical Rehabilitation at the VMCLI! The information provided in this form is greatly appreciated and will expedite your consultation with us so we can spend more time with you and your pet.

* All Fields Are Required

 My Veterinarian
 A friend
 I found you on the internet

We need this information to obtain your pet's medical history and to send records after the evaluation.

Diagnostics include ultrasounds, radiographs, bloodwork, etc. Include the name of the hospital where these were done so we can call for records.

 Neutered Male
 Intact Male
 Spayed Female
 Intact Female


Any coughing, vomiting, diarrhea, decreased appetite, pain, etc.

Examples: degenerative myelopathy, intervertebral disc disease, osteoarthritis, etc.

 Post-Op Surgery (orthopedic/neurologic)
 Arthritis/Geriatric Care
 Conditioning for competition or performance (agility, herding, search & rescue, etc.)

Examples: walk length or duration, frequency of walks, etc.

Please check all that apply.

  Hardwood Floors
  Elevated Food Bowls
  SUV, truck or other large vehicle

Please include species and age.

Please include brand name, kibble/canned, amount and frequency.

This should only include medications requiring prescription from a veterinarian.

This should include any supplements (like fish oils) that can be purchased over the counter.


Grain-free, raw diet, allergies to certain proteins, etc.