Pet Acupuncture NI

Veterinary Referral Form

VETERINARY PRACTICE DETAILS

Practice Name:

Referring Veterinary Surgeon:

Address:

Telephone:

Postcode:

Email:

CLIENT DETAILS

Name:

Home Tel Number:

Address:

Mobile Number:

Postcode:

Email:

ANIMAL DETAILS

Name:

DOB/Age:

Breed:

Sex:

Description/Colour:

CASE HISTORY

Please attach any relevant medical history.

File upload

Primary condition for which acupuncture is being sought:

Any other relevant medical history/conditions:

Current medication:

DECLARATION

This is a patient under my care and has received a full medical health check and examination, and is in my opinion fit to receive acupuncture treatment. I know of no reason why acupuncture should be contraindicated (eg. pregnancy, active skin disease, neoplasia, immunocompromise). I authorise acupuncture for my patient to be carried out by Emma-Jane Hunniford MRCVS Pet Acupuncture NI.

I agree to update Pet Acupuncture NI if there are significant changes to the animals condition which may make acupuncture inappropriate.

Signed:

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Date

Day

Month

Year

Print Name & Qualifications:

Reports will be issued after initial consultation and updates throughout treatment. A final report will be issued on discharge. How would you like to receive vet reports?

Post

Pet Acupuncture NI

Emma-Jane Hunniford BVetMed GPCert(SAS) MRCVS