The veterinarian refers a dog named Breed to a physical therapy specialist and provides the dog's owner and medical details. Progress updates will be sent after the initial assessment and regularly thereafter. The veterinarian or owner can contact the physical therapist anytime with questions.

1. Thank you for your referral. I strive to maintain good communication between myself and the referring
veterinarian. A progress note will be sent to you following the initial assessment and then at regular
intervals there after. Please feel free to contact me at any time with questions or concerns.
shauna@pawsitivelyfit.com 613-449-1907
REFERRAL FORM
Owner’s Name
Address:
Phone Number:
Dog’s name: Breed
Sex: M F Spay/Neutered: Y N
Colour:
Medication(s):
Referring diagnosis:
History of onset:
Relevant Medical History (including previous surgeries and dates):
Precautions/Contraindications to rehab (i.e. laser therapy, manual therapy):
Veterinary’s name (print): _____________________________________________
Veterinary’s signature: ________________________________________________
Clinic Name and Contact Number:_______________________________________
Date:______________________________________________________________