Rehabilitation Referral Form
Please fill out the following information to refer a patient to NS Canine Recovery and Wellness Centre.
Referring Veterinarian Information
Referring Veterinary Clinic
Veterinarian's Full Name
First Name
Last Name
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
If you are not the primary veterinarian, who is this patients primary care vet/vet clinic?
Patient Information
Pet/Patient Name
Patient Weight in kg
Species
Dog
Cat
Breed
Gender
Male
Female
Male Neutered
Female Spayed
Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Estimated
Exact
Owner's Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referral Information
Presenting Complaint:
Please provide a concise summary of the patient’s history, pertinent exam findings, recent and relevant diagnostics performed and current medications and dosages. Please do not defer to medical records.
Current/Relevant History & Medications
Please do not defer to medical records.
Patient Should Be Seen
Next Available Appointment
Priority Appointment
Emergency Appointment
Treatment(s) requested
Rehabilitation Programs
Underwater Treadmill
Other
What "Other" treatment is being requested?
Please Be Aware
That patient will be sent back to the referring veterinarian if diagnostic procedures are needed for building the most effective rehabilitation plan.
Do you, the referring veterinarian, want this patient to have a full assessment with Dr. Rotaru before any treatments start or would you like to send NS Canine Recovery and Wellness Centre an exact prescription with rehabilitation treatment (if you are opting to send a prescription, we will email you a prescription form)?
Full Assessment Please.
Please send the prescription form and I (the referring veterinarian) will take full responsibility of the treatment.
Which treatments do you require a prescription for?
Underwater Treadmill
Laser Therapy
Shockwave Therapy
Prescription Message (Please Read Carefully)
Please note that the patient's initial underwater treadmill session will be conducted as an assisted session. A therapist will be in the underwater treadmill with the patient to ensure their comfort, confidence, and safety throughout treatment. Following the initial session, we will determine whether additional assisted sessions are required or if the patient can safely continue with standard unassisted treatment sessions. As the prescribing veterinarian, you are responsible for determining the patient's treatment protocol, including treatment parameters, frequency, duration, and progression as applicable to the prescribed therapy. Our role is to carry out the prescribed treatment while continuously monitoring the patient's response and ensuring their safety and comfort throughout each session. If, at any time during treatment, the patient is unable to safely tolerate or complete the prescribed therapy, the session will be modified or discontinued as necessary. We will then contact you to discuss the patient's response and request updated treatment directions before future sessions if required. Likewise, if the patient demonstrates significant improvement or changes in condition that may warrant adjustments to the prescribed treatment protocol, we will contact you to obtain revised instructions. As the prescribing veterinarian, you retain responsibility for directing and authorizing the patient's rehabilitation and treatment plan.
Underwater Treadmill Prescription
Please note, water temperature will be between 27-32 degrees.
Water Level
Incline
Total Time
Expected Distance
Increments and Speeds (ie: 0.2mph for 3 min)
How frequently should this patient be seen?
Underwater Treadmill Questions
Rows
Yes
No
N/A
Does the patient have any open wounds and/or incisions?
Does the patient have a draining tract?
Does the patient have a cough and/or fever?
Does this patient have any cardiac diagnosis (ie: Congestive Heart Failure)?
Does the patient have syncope?
Does this patient have a history of seizures?
Does this patient have inadequate perfusion?
Does this patient have a urinary and/or skin infection?
Does the patient have a splint and/or cast that can not be removed?
Does the patient have a urinary and/or IV catheter?
Does the patient have any of the following: Joint/Fracture Instability, Excessive Muscle Weakness, Ruptured or Weak Tendons/Ligaments?
Does this patient have Unmanaged Pain/Joint Inflammation, Levelling Ostomies?
Is this patient able to support their head/neck?
Is the patient pregnant?
Laser Therapy Prescription
Time
Location
Setting
Probe Size
Watts
Joules
How frequently should this patient be seen?
Shockwave Therapy Prescription
Pad Size
Frequency
Pulses
Intensity
Location
How frequently should this patient be seen?
If you have answered yes to any of the above questions, please explain.
Relevant Documents (Please include all relevant x-rays)
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