Skip to content
Home
About
Services
Clinic Form
Contact
Book Online
Book Online
Navigation Menu
Navigation Menu
Home
About
Services
Clinic Form
Contact
Book Online
Book Online
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
Name
*
First
Last
Contact Number
*
Email
Pet Information
Name
Approximate Age
Breed
Gender
Male
Female
Neutered
Yes
No
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?
Yes
No
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:
Please upload additional medical records and radiographs.
Drop files here or
Select files
Max. file size: 32 MB, Max. files: 5.
Phone
This field is for validation purposes and should be left unchanged.
