Acupuncture Referral Form
Client Information
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Primary)
*
Please enter a valid phone number.
Phone Number (Secondary)
Please enter a valid phone number.
How did you hear about our service?
Preferred Form Of Communication
*
Phone
Text
E-Mail
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Pet Information
Pet's Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
What species is your pet?
*
Cat
Dog
Other
Breed
*
Colour
*
Sex
*
Neutered Male
Spayed Female
Intact male (not neutered)
Intact female (not spayed)
Weight
*
*
kg
lbs
Please pick the the most accurate option. When my pet is at the vet clinic:
*
they are calm, explore the room and readily interact with clinic staff and accept treats.
they often won't take treats, and are not eager to explore the room. They prefer to not interact with staff and they may tremble or pant. If they are a cat, they prefer to hide in their kennel, or sit in a loaf position.
they are quite nervous and refuse all treats, even the really yummy ones. If clinic staff come near them, they try to get away, freeze completely, or may swat, growl, hiss or bite.
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Are you a pet owner referring your own pet for acupuncture?
*
Yes
No
Are you a veterinarian referring a client's pet for acupuncture?
*
Yes
No
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Are you a pet owner referring your own pet for acupuncture?
Please fill out the questionnaire below
What is the name of your regular vet clinic? Do you see a specific veterinarian?
*
Vet Clinic Name
Name of Regular Veterinarian
Vet Clinic Email Address
*
Vet Clinic Phone Number
*
Please enter a valid phone number.
Would you like us to send the records from your acupuncture appointments to the above listed clinic?
*
Yes
No
If we recommend further testing and treatment for your pet (outside of acupuncture), how would you like us to proceed?
*
Refer my pet back to my regular vet clinic
Do any testing or treatment recommended at Forest Grove Vet Clinic
It depends on the situation
Current problem/reason for referral:
*
Have you seen a veterinarian for this problem?
*
Yes
No
Has your pet had labwork (bloodwork, urinalysis, etc) with respect to this problem, or in the past 12 months?
*
Yes
No
I don't know
Has your pet had radiographs done for this problem?
*
Yes
No
I don't know
Is your pet currently on any medication or supplements?
*
Yes
No
Please list, including name, dosage, duration:
*
What other health issues or concerns has your pet experienced in the past?
*
Please have your vet clinic send any relevant records (including labwork or radiographs) to contact@forestgrovevet.com at least 24 hours prior to your appointment.
(non-electronic records can also be faxed to 306-955-6101)
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Are you a veterinarian referring a client's pet for acupuncture?
Please fill out the questionnaire below
Name of referring clinic and veterinarian:
*
Vet Clinic
Veterinarian
Number
*
Please enter a valid phone number.
Email Address
*
Brief reason for referral:
*
Preliminary diagnosis:
*
Medical history for the current concern:
*
Has labwork been done for this condition, or in the past 12 months?
*
Yes
No
Have radiographs been done for this condition?
*
Yes
No
Please list all medications and supplements the patient is taking, including drug name, dosage, and frequency of administration:
*
Please provide a brief medical history for any other significant prior health concerns.
*
Please send any relevant records (including labwork or radiographs) to contact@forestgrovevet.com after submission of the referral.
(non-electronic records can also be faxed to 306-955-6101)
For veterinary clinic-based referrals, patients will be referred to their regular vet clinic for any recommended testing and treatments. Acupuncture records will be sent to you via email.
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