Veterinary Provider's Authorization for Equine Rehabilitation

Veterinary Provider's Authorization for Equine Rehabilitation Services

Thank you for considering Bullseye Equine to support the health and wellbeing of your equine clients. Please reach out to me at any time if you would like to discuss this horse's medical history, or if you have any questions or concerns.
Owner/Agent Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Veterinary Provider Information
Name

First NameLast Name
Practice Name (if applicable)
Phone Number
Please enter a valid phone number.
Email
example@example.com
The referenced veterinarian/clinic listed above certifies that the below described equine is an active client/patient.
Equine Information
Name
Age
Breed
Sex
Clinical History/Current Diagnoses
Current Medications/Interventions
Any precautions/concerns? Any cardiac or surgical history?
Additional Notes
Would you like to be emailed a session report?

After initial session onlyAfter each sessionOnly when requested
If there is a different email you'd like reports sent to than listed above, please indicate
Authorization Granted to: Bullseye Equine
Type of Service: Equine Rehabilitation

Reason for Authorization
Equine rehabilitation and other bodywork services are complimentary to veterinary care, and do not diagnose nor treat any bodily ailments.

If there are any veterinary concerns for Bullseye Equine to consider with the equine
referenced herein when rendering rehabilitation services, they have been disclosed to Bullseye Equine.

As the referring veterinarian, I understand that I remain the primary care provider.
Authorization Granted By:

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Veterinarian Name
Date
Please upload any relevant imaging or reports, or forward to BullseyeEquine@gmail.com

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Veterinary Provider's Authorization for Equine Rehabilitation Services

Owner/Agent Information

Veterinary Provider Information

Equine Information