Rehab Agreement/Waiver - Pend Oreille Veterinary Service

Rehab Waiver

Owner(Required)

First Last

Pet's Name(Required)

Phone(Required)

Email(Required)

Physical rehabilitation and/or an exercise program is a joint venture between the pet
owner(s) and the Canine Rehab program at Pend Oreille Veterinary Service. Pet owners
are to take responsibility for their part and make a commitment to the recovery process
and/or exercise program of the treated pet. This commitment includes attending all
scheduled appointments, performing home exercises as assigned, and keeping open
communication regarding progress or changes in the pet’s condition/recovery.

I would like my pet treated at the above-named facility. In support of that treatment I
state the following:

My primary veterinarian is aware that I am pursuing physical rehabilitation and/or
starting a therapeutic exercise program for my pet and has cleared my pet for
such activities. I have given permission for the above-named facility to request
my pet’s medical history, so as to obtain accurate medical records.
I acknowledge that a person trained in canine physical rehabilitation has
discussed treatment with me and has advised me of the risks and
contraindications associated with the treatment of my pet. I understand that in
some instances, certain conditions including but not limited to neck pain of
unknown etiology, certain types of cancer, diagnosed or undiagnosed, may be
exacerbated or worsened by aspects of physical rehabilitation. I have been
informed of and am aware of the potential risks involved as they pertain to my pet.
I have been given and have read any and all applicable materials presented to
me by the facility. I have had an opportunity to have any and all of my questions
answered.
I understand that canine physical rehabilitation is a new and evolving field, and
no guarantees have been made regarding the results that may be obtained.
Any rehabilitation equipment provided by the facility is for the sole purpose of use
with my pet, and not for human use. I also understand that said equipment is
used by my pet at my own risk after appropriate demonstration and instruction in
its use by the above-named facility.
I understand that the facility reserves the right to refuse my pet for physical
rehabilitation and/or an exercise program, especially if it is deemed dangerous to
the staff of the facility, to my pet, the owner, and/or individuals accompanying the
pet to the above-named facility.

Optional Video Consent

I hereby consent and give permission to Canine Rehab at POVS to publish, produce, or otherwise use photographs and/or videos of my pet for the use of instruction, advertising, or other lawful purposes. This includes but is not limited to the facilities website, social media, and/or marketing materials. I do hereby waive any interest I may have in the finished product and all rights to payment or compensation.

Understanding all of the above, I hereby authorize the practitioner/facility and any and all of its employees to provide physical rehabilitation and/or an exercise program for my pet, whatever procedures are deemed necessary.(Required)

I have read the above and accept these conditions and my responsibility.