Veterinary Referral Form

Dear Referring Licensed Veterinarian,

In Wisconsin, for a chiropractor (who is properly trained in adjusting animals) to perform a chiropactic adjustment to an animal, we need a written veterinary referral. The client listed below requests that chiropractic services be provided to their animal(s) through Atlas Animal + Family Chiropractic, LLC, by Dr. Katherine Zietz, DC, cAVCA.

Veterinarian Name*

First NameLast Name

Veterinarian's Clinic / Hospital*

Veterinarian's Email*

example@example.com

Veterinarian's Phone Number

Please enter a valid phone number.

The client listed below is seeking chiropractic care for their animal(s) and requesting authorization by a veterinarian:
[If it is a referral for a farm animal herd, please mark 'Herd' for patient name + sex + age (if not the same year)].

Client Name:   First Name*   Last Name*
Patient Name:   Name*
Species:   Species*
Breed:   Breed*
Age:   MM/DD/YY or Year if unknown*
Sex:   *

If there is more than one animal patient for the SAME client (exception: herds can be listed above), please fill out the animal(s) details below for each individual animal OR submit another referral form for each animal:

(Required info: patient name, species, breed, sex). ex. Coco, dog, lab, spayed female

Correspondence for Specific Client

By checking this box and signing this one document/letter, with permission, this will allow Atlas Animal + Family Chiropractic to treat any animals from THIS CLIENT who is seeking chiropractic. Records can be requested for any patient of THIS CLIENT at anytime. This option will allow veterinarians to save time and not fill out a request every time THIS CLIENT desires chiropractic care. Client will be recommended to inform their veterinary office of the co-management

I, Dr. First Name* Last Name* (referring veterinarian), acknowledge that my client wants their animal(s) to have a chiropractic evaluation and herby authorize Katherine Zietz, DC, cAVCA to provide chiropractic care for the patient(s) identified, as needed. I understand that I can request more information about chiropractic care for animals, or if I want notes from my patient's chiropractic visits for my records.

Any pertinent information that would be important to know about this animal(s):

Additional Records

Optional: Patient files, history, x-rays that may be necessary to provide the best care for the patient

Signature*

Date*

Date

Check if Interested:

I am interested in learning more about animal chiropractic. I am opened to meeting up with Dr. Katherine to discuss more about animal chiropractic and/or getting more resources.I am interested in learning how farm herds (cattle, sheep, chickens, goats, etc.) can benefit from chiropractic care.I would like to learn more about how adding a chiropractor to my patient's health care will help relieve stress from my veterinary life and help improve patient outcomes.I am interested in signing one letter to allow any of my patients from my practice to seek care with a signed permission for treatment. Records for patients can be requested at anytime. Correspondence letter will be provided for signature and can be customizable, if necessary. Checking this box does not finalize permissions for all animals to seek care until signed correspondence letter is returned.Interested in being listed as a chiropractic-friendly referral partner.

Please reach out if you need any reports for your records.

*Dr. Katherine is a licensed chiropractor. She has a degree in Animal Science from Iowa State University and is a Palmer College of Chiropractic graduate. She has 240+ hours of animal chiropractic education through Animal Chiropractic Education Source, in Texas, along with doing a Food Animal Adjusting course. She is board certified through the American Veterinary Chiropractic Association (AVCA) and will continue to stay up to date with animal chiropractic continuing education.

*Animal chiropractic does NOT replace traditional veterinary medicine. Employees of Atlas Animal + Family Chiropractic are NOT veterinarians, and employees do not intend to replace traditional veterinary care or take responsibility for the primary healthcare need of the animal(s). Animal chiropractic is a complementary method to add to an animal's health care.

*This referral is in compliance with the laws of the Wisconsin Board of Veterinary Medicine.

In Health,
Dr. Katherine Zietz

Atlas Animal + Family Chiropractic, LLC
Mobile Chiropractic Practice
P: (715) 500 4248 F: (715) 504 8997
Email: atlaschiropracticwis@gmail.com