Dog's Name    

Breed

Age:       Weight (in pounds)      Sex:  Please Select Female Male

Date of Vaccinations:

* Reason for requesting Hip Dog Services:

Referred by:

* Your Name:        

Address             

City                   

State                     zip code 

* Home Phone:     

Work Phone        

Cell Phone         

* Email Address   

Veterinarian, Clinic or Animal Hospital: 

Address:     

Telephone: 

Fax           

Has your dog previously been in the water?   Please Select Yes No

If yes, did your dog enjoy the experience?  Please Select Yes No

Hip Dog requires proof of current rabies, distemper, and bordatella vaccines before any dog is allowed in the pool area.

Upon receiving this form, one of our therapists will contact you to discuss your dog's needs and arrange your pet's initial session. Hip Dog works in partnership with your veterinarian to ensure your pet receives optimum care. When possible, we prefer to consult with your veterinarian prior to your first session in order to provide your pet with the most beneficial treatment suited for his/her medical condition.

Thank you for choosing Hip Dog to be part of your dog's health care team. We are dedicated to your dog's quality of life!