Veterinary Referral Form

In order to evaluate an animal, we must have a written veterinary referral from a licensed veterinarian.

First Name Last Name is requesting authorization for a veterinary referral for chiropractic care for pet Blank . Type a label requests that chiropractic services be provided by Dr. Molly Mehlman, D.C., at Nose to Tail Animal Chiropractic. Type a label has been provided with the risks and benefits associated with animal chiropractic and understands that referring veterinarian will not be held liable should any negative reactions to chiropractic care occur. Type a label also understands that the employees of Nose to Tail Chiropractic are NOT veterinarians and they do not intend to replace traditional vet care or take responsibility for my animal’s primary healthcare needs.

I, blanks* (referring veterinarian), herby authorize Dr. Molly Mehlman D.C. to provide chiropractic care as needed for the patient(s) identified above. This referral is in compliance with the laws of the Wisconsin Board of Veterinary Medicine.

Please check all that apply:*

The patient has been seen in my clinic and and I'm comfortable referring for chiropractic carePlease send copies of SOAP notes after new patient appointments and when new complaints arisePlease do not send me any additional information or SOAP notes. Only consult me if a traditional veterinary condition or emergency arises.I would like to learn more about animal chiropractic and am open to Dr. Molly dropping off resources/flyers at my office

Veterinarian Name and Clinic *

Signature*

Feel free to write any pertinent information about this pet down below: