Rehab Referral

Form to be completed by veterinary staff only

Referring Veterinarian

Would you like us to contact your client to set up their initial assessment?

Yes, please call them No, they will contact you

Client Information

Patient Information

Sex

Unknown

Up to date on core vaccines?

Yes No

Referring Information

Condition(s) being referred for. Please include details and date of onset/treatment/surgery:

Please attach referral/surgical reports if applicable:

Add Condition

Important medical history (i.e. any history of neoplasia, diabetes mellitus, heart disease, seizures, etc.):

Please attach medical history:

Add Medical History

Were radiographs taken?

Yes No

Current medications or supplements and dosages:

Add Medication/supplement/dosage

I, the referring veterinarian listed on this form hereby authorize the Certified Canine Rehabilitation Practitioners and staff at Allandale Veterinary Hospital to perform physical rehabilitation therapies with the identified patient.

Signature :

Allandale's Rehab Referral Patient Policy:

We fully respect the relationship pets and clients have with their family veterinarians and out of a mutual respect to our surrounding veterinary clinics we will not offer any routine veterinary care (i.e. routine exams, vaccinations, medication prescriptions, etc.) to your patients.

We look forward to working with you and your patient on their rehabilitation journey!