Indian River Health Center Veterinary Referral Form

Veterinary Referral Form
Indian River Health Center must have a written veterinary referral from a licensed veterinarian to provide care.
Name of Pet Owner*

First NameLast Name
Name of Pet*
This client requests that chiropractic services be provided by Dr. Ryan Hess, DC, CVSMT, CoAC at Indian River Health Center for their pet named above. The client has been provided with the risks and benefits associated with animal chiropractic and understands that the referring veterinarian will not be held liable should any negative reactions to chiropractic care occur. The client also understands that the employees of Indian River Health Center are NOT veterinarians, and they do not intend to replace traditional vet care or take responsibility for my animal’s primary healthcare needs.
Please check all that apply:*

The pet has been seen in my clinic, and I am comfortable referring them for chiropractic care.Please send copies of SOAP notes after new patient/pet appointments and when new complaints arise.Please do not send me any additional information or SOAP notes. Only consult me if a traditional veterinary condition or emergency arises.
Please note important information about this pet:*
Veterinarian Name*

First NameLast Name
Veterinarian Clinic Name*
Veterinarian Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Veterinarian Phone
Please enter a valid phone number.
Veterinarian Email
example@example.com
Consent for Treatment:
I, {veterinarianName} hereby authorize Dr. Ryan Hess, DC, CVSMT, CoAC to provide chiropractic care as needed for the pet identified above. This referral is in compliance with the laws of the Florida Board of Veterinary Medicine.
Veterinarian Signature:*

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Veterinary Referral Form

Consent for Treatment: