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Our Services
For Clients
Contact
Pet Resort

Rehabilitation Referral Form

Canine rehabilitation services are offered exclusively and do not establish a veterinarian-client-patient relationship (VCPR). Following treatment, patients will be referred back to their primary veterinarian for ongoing care. Progress reports and treatment updates will be emailed to the referring veterinarian to ensure continuity of care.

Please be sure to complete all steps, including information for the referring veterinarian, owner, and patient.

Comments

This field is for validation purposes and should be left unchanged.

Referring Clinic Info

Referring Veterinary Clinic(Required)

Veterinarian(Required)

Clinic Phone Number

Clinic Email

Clinic Address

Street Address Address Line 2 City State ZIP Code

Owner Info

Client Name (Owner)(Required)

First Last

Client Phone Number(Required)

Client Email(Required)

Client Address

Street Address Address Line 2 City State ZIP Code

Patient Info

Patient Name(Required)

Species(Required)

Breed(Required)

Age/DOB(Required)

Sex(Required)

Male

Female

Spayed/Neutered(Required)

Male

Female

Weight

Medical Info

Primary Diagnosis(Required)

Date(Required)

MM slash DD slash YYYY

Relevant History(Required)

Concurrent Issues(Required)

Vaccines Up to Date:(Required)

Surgery(Required)

Yes

No

If Yes, Procedure Type, Date, and Location(Required)

Current Medications(Required)

Diagnostics (if available)(Required)

Radiographs

MRI/CT

Bloodwork

Surgical Report

Diagnostic Upload

Drop files here or

Max. file size: 128 MB.

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