Veterinarian Referral
Notice
Your client has requested that Connect Animal Chiropractic provides their animal with chiropractic care. Please be advised that:
Minnesota state law requires licensed chiropractors to obtain a referral from an animal’s primary veterinarian prior to providing chiropractic care.
Dr. Brittany Freese is NOT a licensed veterinarian and therefore understands that chiropractic care is an adjunct to traditional veterinary care.
Dr. Brittany is certified in Veterinary Spinal Manipulative Therapy by the Healing Oasis Wellness Center in Sturtevant, WI. This program has been approved for continuing education and training in veterinary spinal manipulation by the American Veterinary Chiropractic Association.
Dr. Brittany is licensed in the state of Minnesota as a Doctor of Chiropractic with License number 5891 and Animal Chiropractic Registration number 047 by the Minnesota Board of Chiropractic Examiners.
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Veterinarian Information
Clinic/Hospital Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Doctor Name
*
First Name
Last Name
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Owner Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Animal Information
Name
*
Please list any special considerations such as contraindications or other health related matters that may influence chiropractic care.
*
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Authorization of Care
I hereby authorize Connect Animal Chiropractic, LLC, in particular Dr. Brittany Freese, DC, CVSMT, to treat above animal with animal chiropractic.
Signature
*
Thank you for your referral!
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