Veterinary Referral for Animal Chiropractic

Veterinary Referral for Animal Chiropractic
Thank you for coordinating care for animals. This form must be completed by a licensed veterinarian who is familiar with the animal's health history prior to the initial chiropractic exam. Chiropractic care does not replace traditional veterinary medicine, and all animals are required to be under veterinary care.

Dr. Natalia LaVallie, DC, cAVCA is a licensed Chiropractic Physician in Illinois (Lic. #038.013140) and maintains certification in animal chiropractic with the Animal Chiropractic Certification Commission (Cert. #1317). She carries malpractice and liability insurance specifically for the administration of chiropractic care to animals (ChiroSecure Pol. #COVC2020). Additional information available at barnyardchiropractic.com.

If you have any questions about completing this form, please call/text 630-394-4228 or email drnatalia@barnyardchiropractic.com.
Patient Name*
Owner's Last Name*
Species*
Breed
Birthday (if known)

MonthDayYear
Date
Age (Years)*
Sex*

MaleFemale
Sex*

IntactAltered (e.g., spayed/neutered, gelded)
Owner Name*

First NameLast Name
Owner Phone Number*
Please enter a valid phone number.
Owner Email
example@example.com
Referring Veterinarian Name*

First NameLast Name
Veterinary Practice Name
Referring Veterinarian Phone Number*
Please enter a valid phone number.
Referring Veterinarian Email*
example@example.com
Current Veterinary Differential Diagnosis (if available).
If none, please write "none."
Relevant History & Clinical Findings
If none, please write "none."
Medications
Records (Upload)

Please upload any relevant records like radiology reports. X-ray viewing links should be emailed separately.
Cancelof
Additional Comments or Special Instructions
By signing below, Dr. {q14_fullname12} acknowledges that {q10_fullname8} would like their animal {patientName} to receive chiropractic care.
Veterinarian Signature*

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