Rehabilitation Registration I was referred to Sunset Hill for rehab services by:Name* First Last Phone*Name First Last PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* During regular office hours how would you generally prefer we contact you: First Phone Number Second Phone Number EmailMy Primary Care Veterinarian/Vet Clinic is:Pet Health HistoryName of petSpeciesDogCatBreedColorAge or DOBSexMaleMale-NeuteredFemaleFemale-SpayedIf your pet has done any physical rehabilitation before please list it here:Authorization:I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet.I assume responsibility for all charges incurred in the care of this animal.I also understand that professional fees are due at the time services are rendered and that a deposit may be required for surgical treatment.We will gladly prepare a written estimate if you desire. Please ask any staff member.SignatureDate Date Format: MM slash DD slash YYYY Non-Compete AgreementPlease list the name and hospital that referred you:I have been referred to this practice by the above Dr at the above veterinary clinic/hospital and consider him/her to be my primary care veterinarian. I understand that I am seeing Dr. Lamb for rehabilitation purposes only. Dr. Lamb will communicate with my primary care veterinarian and if she feels that any non-emergency veterinary diagnostics are needed I will return to my primary care veterinarian to receive these services.I agree that I will not seek veterinary medical services, diagnostic support and/or request any other veterinary support, other than that related to physical rehabilitation, from Dr. Lamb or Sunset Hill Veterinary & Rehabilitation Center.SignatureDate Date Format: MM slash DD slash YYYY Video-Photo ReleaseI grant Sunset Hill Veterinary & Rehabilitation Center, its representatives and employees the permission to take pictures and/or video of me and/or my pet(s), and to use, copyright, and/or publish the same in print and/or electronically.I agree that Sunset Hill Veterinary & Rehabilitation Center may use such pictures and/or video of me and/or my pet(s) with or without the name(s) of my pet(s) and/or my name and for any lawful purpose, including, for example, such purposes as educational, publicity, advertising, and Web content. The above may take photos of me and/or my pet(s) The above may NOT take photos of me and/or my pet(s)Pet name:SignatureDate Date Format: MM slash DD slash YYYY UNDERWATER TREADMILL POLICYFor the safety of every patient, client, and employee at Sunset Hill Veterinary & Rehabilitation Center we ask that you review the following policy carefully. If you have any questions, please feel free to ask before signing.We request that patients have urinated and defecated prior to any underwater treadmill session. This will help to prevent any accidental soiling in the underwater treadmill.If your dog/cat has not defecated or has trouble defecating please let us know and we can determine if a fecal stimulation is needed.Please alert the technician if your dog/cat has any new illness (diarrhea, vomiting, lethargy) or injury (new lameness or open wound) as the underwater treadmill can exacerbate these potential problems. Depending on the issue at hand the technician may cancel the underwater treadmill session and continue on with exercises, massage, or laser therapy if this applies.If your dog/cat is experiencing diarrhea please call to reschedule the underwater treadmill session for a later date after the diarrhea has resolved.If your dog/cat defecates in the underwater treadmill there will be an extra charge of $50.00 and the session will be terminated immediately at full charge.Patients will lose their underwater treadmill privileges after the third time they defecate in the treadmill.I, the undersigned, care giver of the pet listed above have read, understand, and agree to the stipulations in the underwater treadmill policy.SignatureDate Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
