Dry Pond Animal Hospital Rehabilitation and Physical Therapy 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 provided to the referring veterinarian via email to ensure continuity of care.

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

Referring Veterinary Clinic

Veterinarian

Clinic Phone Number

Clinic Email

Clinic Address

Client Name (Owner)

Client Phone Number

Client Email

Client Address

Patient Name

Species

Breed

Age/DOB

Sex

Spayed/Neutered

Weight

Primary Diagnosis

Date

Relevant History

Concurrent Issues

Vaccines Up to Date:

Surgery

Yes No

If Yes, Procedure Type, Date, and Location

Current Medications

Diagnostics (if available)

Radiographs MRI/CT Bloodwork Surgical Report

Diagnostic Upload