Correspondence 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.

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.

This document is to confirm how you would like to be contacted and what type of correspondence you want from Atlas Animal + Family Chiropractic, LLC. This document is for Atlas Animal + Family Chiropractic, LLC and your records regarding patients who would like chiropractic care. This method of correspondence can be changed at any time (please contact us) and records may be requested at any time for any patient. Being able to co-manage care will help to build a strong support system for clients and their animals to provide the best outcomes.

Correspondence Options*

Atlas Animal + Family Chiropractic will require all of your clients/patients, seeking chiropractic care, to have you (the veterinarian) fill out a document for every individual.By checking this box and signing this one document/letter, with permission, this will allow Atlas Animal + Family Chiropractic to treat any patients from your practice who are seeking chiropractic. As noted above, records can be requested for any patient at anytime. This option will allow veterinarians to save time and not fill out a request every time a patient desires chiropractic care. Clients will be recommended to inform their veterinary office of the co-management.

Optional: Customization Requests

Ex: email or call practice when a patient of the clinic/hospital is seeking chiropractic care etc.

When chiropractic is performed by trained professionals (veterinarians or chiropractors who have recieved proper animal chiropractic education), chiropractic is a safe service and a great addition to an animal's care team. A client, whose team works together, will get the best results for their animals creating less stress and emergency situations for the veterinarians, the owners, and others on the team.

Signature*

Date*

Date

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