Your client has requested that I provide chiropractic services for the animal that is listed below. Your name and/or clinic was provided as a health care provider for this patient. According to IN law, before chiropractic adjustment is performed, your referral is needed. The client understands that this referral does not hold you or your clinic liable for any chiropractic services rendered to the patient.
To provide the referral that your client has requested, please:
∙ review and sign this form,
∙ indicate the level of communication regarding care that you would like to receive,
∙ submit this form
I am a licensed chiropractor in Indiana and hold license #08003416A. I have completed an accredited animal chiropractic program through A.C.E.S. in Meridian, TX. If you need any additional information, please feel free to reach out by phone or email.