Integrative and Holistic Consult and Treatment Referral FormReferring Veterinary Information:Referring VeterinarianReferring Veterinary ClinicClinic Address Street Address City State / Province / Region ZIP / Postal Code Email Address* PhoneFaxCommunication Preference Phone Fax e-mail Referring Veterinary Information:Client / Owner name*Client Address Street Address City State / Province / Region ZIP / Postal Code Phone*Client Address* Pet InformationPet’s nameSpeciesBreedSexAge / BirthdateWeightTemperamentReferral Information:**Please attach all pertinent patient medical records. ** Please send all medical records and diagnostic test results and x-rays 48hours before the scheduled appointment. This will give us time to thoroughly review them and allow us to better assist your client in providing the most beneficial integrative diagnostics and treatments.Presenting Complaint / Reason for referralHistoryPreliminary / Definitive DiagnosisTreatments Performed, Medication Dosages & Last Time GivenDiagnostic TestingHas diagnostic testing been performed in the last 30 days? Yes No If Yes please indicate all that apply CBC Chemistry Panel T4 Urinalysis Cytology Biopsy Culture and Sensitivity Skin Scraping DTM / fungal cultures Allergy testing X-rays ultrasound Other Upload Lab Work and ImagesMax. file size: 256 MB. Upload Medical History and ChartsMax. file size: 256 MB. Integrative / holistic services requested (Please select all that apply): General Integrative / Holistic Consult Traditional Chinese Veterinary Medicine (TCVM) Consult Acupuncture Chinese herbal medicine Chinese food therapy Essential Oils / Veterinary Aromatherapy Laser therapy *** Regarding selected and desired treatments: While every effort will be made to provide the specific treatment requested by the client and the referring veterinarian, the specific treatment protocol will be chosen based on the patient’s history, integrative exam and diagnostics, specific needs of the pet, and the ability of the client / owner to follow through with treatments. We look forward to working with you and your client to provide their pets the best integrative and holistic veterinary care available. Working together we can provide a balanced treatment plan combining the best of both aspects of veterinary care. Thank you for your trust and your referral.
