Acupuncture Referral Form
Please complete the form below to request a visit with Dr. Kim Mitchell DVM CVA
Client's Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Pet's Name
Name of referring veterinarian:
Reason for referral:
Please list any current medications with dosage:
What treatments have you tried?
Do you have a laser machine at your office?
Yes
No
Other
Please upload any recent lab work and diagnostic imaging:
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