CLIENTS NAME *

First Name

Last Name

CLIENTS PHONE NUMBER *

(###)

###

####

CLIENTS ADDRESS *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

SPECIES *

Canine

Feline

PATIENT SEX

Female

Female Spayed

Male

Male Neutered

MOST RECENT VISIT WITH YOUR CLINIC

MM

DD

YYYY

CONTRAINDICATIONS

Cardiac Dysfunction

Respiratory Dysfunction

Bleeding/Hemorrhage

Incontinence/Diarrhea

Open/Draining Wounds or Incisions

Epilepsy

Hypothyroidism

Diabetes

None of the Above

RECOMMENDED TREATMENTS

Up to therapists assessments

Hydrotherapy

Laser Therapy

Therapeutic Ultrasound

Electrical Stimulation

Massage Therapy

ROM/Strengthening Exercise

All of the Above

I, the referring Veterinarian listed on this form, hereby authorize the certified practitioners and therapists at Touch Animal Rehabilitation to perform physical rehabilitation with the identified patient treatments *

Yes