Referral form with veterinary consent to participate in physical rehabilitation at Stretch and Fetch Rehab.
Clinic Name *
Consenting Veterinarian *
Contact Number *
Email
Full Name *
Name
Approximate Age
Breed
Gender MaleFemale
Neutered YesNo
Diagnosis
Brief History of Problem
Current Medications
Other Relevant Information
Comprehensive Rehabilitation Consultation with Janelle Merritt, DVM and rehab practitioner, Marissa DuBois, RVT, CCRP;Rehabilitation (may include laser therapy, electrical muscle stimulation, therapeutic exercise, massage); *Non-Complicated Post Surgical Rehabilitation; **Weight Loss Program;Osteoarthritis Management;Laser Therapy;Home Exercise Plan & Lifestyle Management.
Other
* Must accompany a rehab consultation unless listed below. ** Rehab consultation not required.
Is a recheck required from the regular DVM to continue rehab? YesNo
If yes, please provide the date a recheck is required.
I would like Stretch & Fetch brochures sent to my clinic;I would like to book a rehab information session for my clinic with Marissa DuBois, RVT, CCRP.