Physical Rehabilitation Referral Form

Client's Name

First NameLast Name

Client's Address

Client's Phone Number

Please enter a valid phone number.

Client's Email

example@example.com

Patient's Name

Species

Breed

Date of Birth

Date

Presenting medical concerns and diagnosis. *A diagnosis is needed as this is a direct referral to a non DVM rehabilitation therapist/ Certified Canine Rehabilitation Practitioner

Surgical and/ or other procedures performed and date(s) that are relevant to rehabilitation

Current medications and supplements:

Has this patient ever required a muzzle or sedation to be examined?

Rehabilitation Services Requested

ex. Rehabilitation (includes therapeutic modalities/ exercises), Laser Therapy (individual service), Conditioning

Name of Referring DVM

As the referring DVM, I understand that I remain the primary care provider for this patient. The patient mentioned above will ONLY be seen at the Strathroy Animal Clinic for rehabilitation services and will not be seeing a DVM for any visits with us.

Referring Clinic Name

Referring Clinic Phone Number

Please enter a valid phone number.

Referring Clinic Email

example@example.com

Please sumbit the referral form and send any relevant patient records to strathroyclinic@rogers.com. Once we have recieved this referral form our rehabilitation therapist will send you a "Rehabilitation Therapy Plan" to be approved and signed by the referring DVM. Once the signed "Rehabilitation Therapy Plan" has been recieved, we will contact the client to book thier first appointment.