Veterinary Referral Form
This form is to be completed by the referring veterinarian. It is a legal requirement that Fur Ability Animal Rehabilitation Inc. have a completed signed referral form. No treatment will take place without a completed referral form.
Referring Veterinarian Information
Name of referring veterinarian
First Name
Last Name
Hospital name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hospital email
example@example.com
Hospital phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Veterinary Hospital name
Please complete if you are not the patients primary Veterinary Hospital
Name of primary veterinarian
First Name
Last Name
Client Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a hospital phone number.
Format: (000) 000-0000.
Patient information
Patient Name
First Name
Last Name
Species
Breed
Colour
Age (Date of Birth if known)
Weight
Gender
Spayed/neutered
Please Select
Yes
No
Insured
Please Select
Yes
No
If insured please provide company and policy number
Fur Ability is no longer offering home visits. If your client requires a home visit please contact us directly and an exception may be able to be made for extenuating circumstances
I understand
I will contact client directly
How urgent is this referral?
Please Select
1. Urgent 1-2 weeks (additional fees may apply)
2. Semi-urgent 2-3 weeks
3. Routine 3-6 weeks (booked into next available appointment)
Please note: standard booking times for new patients are typically 3–6 weeks currently, depending on availability. This is subject to change depending on demand.
Urgent
1
2
3
4
Routine
5
1 is Urgent, 5 is Routine
For post-operative patients not yet cleared for rehabilitation ONLY. When do you anticipate this patient will be cleared for rehabilitation?
(An approximate date is fine. Providing this helps us schedule ahead so the patient can begin rehab as soon as they are stable, minimizing delays in care and reducing the risk of compensatory issues during recovery.)
Preference of therapist. Please note the choice of therapist is not a guarantee and we may offer a different therapist more suited to the case.
No preference
Kirsty Powell-Palmer
Erin Piercy
Emily Grant
Medical history
Diagnosis of condition for which the patient is being referred
*
Other comorbidities
Has the patient had a 4DX test since the onset of symptoms? If so when.
Case summary
*
For post operative patients please provide a brief summary of surgery, location, date, expected outcome, any complications etc
For BEHAVIORAL pain assessment referrals ONLY: Is the patient a bite risk? Is the patient muzzle-trained? Does the patient require a four-week period for medications to be initiated before the assessment can occur?
Current medications. Please include name, date started, length of course if applicable dosage and frequency.
*
Diagnostics performed to date (BW, Radiographs, ultrasound, CT etc) and summary of results - Please include information from referral, 2nd opinion or primary care vets
*
Please provide a summary. If needed full reports can be attached or emailed to furabilityrehab@gmail.com
Full medical records - Please include information from referral, 2nd opinion or primary care vets
*
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Lab reports - Please include information from referral, 2nd opinion or primary care vets
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Radiographs- Please include radiographs from referral, 2nd opinion or primary care vets as well
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Please include radiographs taken relating to current complaint
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Additional Information: Please provide any reports or notes from second opinions, specialists, and/or primary care veterinarians if not already uploaded above. We require a complete medical history from all veterinarians involved in the patient’s care to ensure we can provide the best possible treatment.
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Signature of referring DVM
*
Fur Ability Animal Rehabilitation Inc. is authorized to provide rehabilitation services for the diagnosed condition. An individualized treatment plan will be developed and implemented. Treatment may be discontinued if the patient's condition changes, pending a re-assessment by a licensed DVM.
Name
*
Prefix
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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