Veterinary Consultation Form

This form must be signed by a licensed veterinarian. A copy of this form will be sent to the veterinary clinic for the patient's records.

Name (Veterinarian)

Clinic/Practice Name

Phone Number

Website

Address

Dog's Name

Owner(s) Name(s)

Date

Month

Day

Year

This case:

This dog is an appropriate case for chiropractic care. No additional information required to start chiropractic care.

There are important details about this dog, please see below.

Concurrent treatment for this dog is required, please see details below.

Diagnosis/Details/Findings/Important Information

Signature

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Please note: A copy of this form will be sent to the veterinary clinic/veterinarian listed on this form.