Texas Veterinary Referral Form

Rehab 4 Pets is a rehabilitation practice for small animals. We offer hydrotherapy (underwater treadmill),
extracorporeal shockwave therapy, extracorporeal mechano-transduction therapy laser,
chiropractic, customized bracing, exercise therapy and more.

Prefer To Use Pen & Paper?

Should you not want to complete the form below,
please download the Texas Veterinary Referral Form.

Download Vet Referral PDF Form

FOR VETERINARIAN TO COMPLETE

Texas Veterinary Referral Form

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Client & Patient

Vet (Your) Email

Veterinary Clinic Name

Client's Name

Client Cell Number

Patient (Animal) Name

Diagnosis

Please include all pertinent medical information including medication profile, pre-existing conditions, diagnostic results, and any other relevant information.

Precautions or Contraindications

Other Medical Conditions and Medications

Signature & Agreement

I as veterinarian have performed the following: 1. Established a valid veterinarian/client/patient relationship. 2. Examined the animal(s) to determine that the above therapies are appropriate.

Disclaimer: Per Rule 573.14 of the Texas Administrative Code, the supervising Veterinarian will have established a veterinarian/client/patient relationship and determined that rehab services (an alternate therapy) will not likely be harmful to the patient.

Full Name as Signature (Yours as Vet)

First

Last

Please provide your full legal name as signature in agreement of the above.