Referring Veterinary Clinic Name

Referring Veterinarian Name

Referring Veterinary Clinic Phone Number

Referring Veterinary Clinic Email Address

Client Name*

First Last

Primary phone number*

Alternate phone number

Client Email Address

Preferred method of contact

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pet Patient Name*

Species*

Canine
Feline

Breed

Age

Patient Sex

M
MN
F
FS

Last recorded weight

Vaccine Status *note last vaccine type & date, include Rabies Vaccine*

Co-morbidities & Medical Conditions

Condition to be treated*

Diagnostics performed

Bloodwork
Radiographs
CT
MRI
Other

If Other

Current Medications

note dose & frequency (Please list all, including nutraceuticals & supplements)

Requested Therapies*

Dependent on Therapist's Assessment
Laser Therapy
Therapeutic Ultrasound
NMES
TENS
Manual therapy
Therapeutic exercise program
Assistive devices

(select all that apply)

Additional Comments / Important Notes

Policy

I hereby authorize Judith Emery, RVT & Certified Canine Rehabilitation Practitioner to perform physical rehabilitation treatments with the identified patient as detailed above. I understand that Judith Emery will provide me with case notes of all appointments and refer any questions or concerns about patient care directly to me.

Referring Veterinarian Signature (Printed Name)*

Date*

MM

DD

YYYY

Rehabilitation Referral Form

Policy