HT Animal Rehabilitation

HT Animal Rehabilitation referral form

To be completed by the registered Veterinarian

Veterinarian details

Name

Veterinary Practice name:

Owner Details:

Owners Name

Telephone Number:

Address:

Animal details:

Name

Age:

Species

Gender:

Breed:

Current medications

Diagnosis/reason for referral?

Contraindications to treatment:

In your professional opinion, is the dog in a fit condition to receive physiotherapy/ McTimoney chiropractic treatment?

I hereby certify that I have examined the above-named animal and I can find no reason, unless stated, why this animal should not receive physiotherapy and/ or chiropractic treatment.