Clinic Form

Veterinary Consent Form

Referral form with veterinary consent to participate in physical rehabilitation at Stretch and Fetch Rehab.

Consenting Veterinarian Information

Clinic Name *

Consenting Veterinarian *

Contact Number *

Email

Client Information

Full Name *

Contact Number *

Email

Pet Information

Name

Approximate Age

Breed

Gender
MaleFemale

Neutered
YesNo

Diagnosis

Brief History of Problem

Current Medications

Other Relevant Information

Stretch & Fetch Services Requested

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.

Special Requests

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.

Other