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New Patient Center

Welcome to the Tampa Bay K9 Rehabilitation New Patient Center!

Find out how our website can help you as a new family member by using our online forms and information and learn what to expect here at Tampa Bay K9 Rehabilitation Center. Please feel free to explore our virtual office tour and veterinary resources, as well as the different payment options that we offer.

New or Referred Client Information


Pet Guardian Information


IMPORTANT: Please review our Financial Policy for important information prior to completing this form.

Your Name (*)

Please let us know your name.
Pet Insurance? (*)

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If so, which insurance?

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Your Email (*)

Please let us know your email address. (See privacy policy below)
Spouse or Companion's Name

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Driver's License (*)

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Main Contact Phone (*)

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Second Contact Phone

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Address (*)

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City, State & Zip Code (*)

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Employer

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Work Phone

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Extension

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How did you first learn about us? (*)

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Add more info if asked for above

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Pet Information


You will get a chance to add another pet (if applicable) on the next page.

Dog's Name (*)

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Age (*)

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Breed (*)

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Colors / Markings (*)

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Gender (*)

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Spayed or Neutered? (*)

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Immunization Records


Distemper/Parvo

Date of LAST immunization (*)

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Type of vaccine (*)

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Rabies

Date of LAST immunization (*)

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Type of vaccine (*)

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Bordatella

Date of LAST immunization (*)

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Type of vaccine (*)

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Leptospirosis

Date of LAST immunization (*)

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K9 Influenza

Date of LAST immunization (*)

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Your Pet's Condition

Reason your pet is here? (*)

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Add more info if asked for above

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How long has your pet had this problem? (*)

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What are your expectations? (*)

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Pet Information


Please add info for your second pet (if applicable).

Dog's Name

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Age

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Breed

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Colors / Markings

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Gender

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Spayed or Neutered?

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Immunization Records


Distemper

Date of LAST immunization

Invalid Input
Type of vaccine

Invalid Input




Rabies

Date of LAST immunization

Invalid Input
Type of vaccine

Invalid Input




Bordatella

Date of LAST immunization

Invalid Input
Type of vaccine

Invalid Input




Leptospirosis

Date of LAST immunization

Invalid Input




K9 Influenza

Date of LAST immunization

Invalid Input




Your Pet's Condition

Reason your pet is here?

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Add more info if asked for above

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How long has your pet had this problem?

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What are your expectations?

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Payment Information

Please select payment method you intend to use

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IMPORTANT:

By clicking submit below, you are verifying and agreeing to the following statements:

  • You understand that all fees must be paid at the time that services are rendered.
  • You are the responsible party for the payment.
  • You have read and understand the financial policy.



Doing our part to keep you safe from SPAM

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New Patient Information Form


If you have multiple pets that are going to be using our services at this time, please complete this form for each one.

Your Name (*)

Please let us know your name.
Your Email (*)

Please let us know your email address. (See privacy policy below)
Dog's Name (*)

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Age (*)

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Breed (*)

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Colors / Markings (*)

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Gender (*)

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Spayed or Neutered? (*)

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Name of referring veterinarian

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Reason for this visit (*)

Please let us know your message.
Date of injury (*)

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How did injury occur?

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Has injury occurred before? (*)

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If so, how many times has this injury occurred in the past?

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List any previous or current medical issues your dog has experienced.

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List all current medications your dog is taking. (Include heartworm prevention and flea control.)

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List all supplements your dog is taking.

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Type of food your dog eats?

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How much food is eaten in a day?

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How often is your dog fed? (*)

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Does your dog use a raised bowl? (*)

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Do you give your dog table scraps? (*)

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Do you give your dog treats? (*)

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Describe your dog's living conditions.

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Does your dog have to use stairs?

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Is you dog allowed on the furniture?

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Where does your dog sleep?

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What type of flooring is in your home?

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List any other pets living in your home.

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Is your yard fenced?

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Does your dog use a doggie door?

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How many days (if any) is your dog crated each week? (*)

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How many hours (if any) is your dog crated each day? (*)

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What motivates your dog?

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If other, please explain.

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What are your expectation of rehab?

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Work-up Performed by Referring or Previous Veterinarian


Note: Please bring all history (medical records, Xrays, myelogram, bloodwork results) with you to your rehabilitation consultation appointment for the doctor to review.

If x-rays were taken, what was the date?

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Bloodwork

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Neuro / Musculature Exam

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Myelogram

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Doing our part to keep you safe from SPAM

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Privacy Policy:

We value your privacy and know that you trust us. Your contact information will never be shared with or sold to anyone. It will only be used to communicate with you.