Referral Form

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Referral Form

Thank you for referring your patient to Dr. Heather Misener at Ruff Day for rehabilitation, acupuncture, and/or shock wave therapy. I know your time is valuable, and I appreciate you filling out this brief referral form.

Referring DVM's First and Last Name *

Don't be shy--if you are a specialist or have extra certifications, please list all the pertinent letters after your name.

Clinic Name *

Best Email to send updates to: *

If you prefer updates being sent by another method, please list that method here with applicable contact info.

Owner's First and Last Name *

Owner's preferred method for us to contact them for scheduling, with contact information. *

Pet's Name and Signalment *

For what condition(s) are you referring this patient? *

Are you referring your patient for rehabilitation and/or acupuncture therapy in general, or are looking to refer your patient for shock wave therapy only? *

I am comfortable with you making any recommendations for this patient that you feel is appropriate.

I have discussed a referral with this client, and they have elected to just pursue shock wave at this time, but I am comfortable with you recommending other therapies at the shock wave appointments, if you feel they are appropriate.

My client and/or myself are only interested in a shock wave package at this time. NOTE: shock wave packages are only available to clients by direct referral from a managing Veterinarian. The package cost is $1000 and includes a 1-hour consultation and treatment appointment on day 1, followed by two further 15-minute treatment appointments two weeks apart. We will arrange scheduling and payment with your client directly.

Do you have any concerns/restrictions about rehabilitation or acupuncture therapy in this patient that you wish to discuss with me prior to my appointment with them? (If yes, please include an email address or phone number as the best way to contact you) *

Check all that apply: *

My staff will send records, including recent labs and images, to vet@ruffday.vet within 1 business day.

My staff cannot send records by email--please call our office to make arrangements.

My clinic needs Ruff Day business cards and brochures to pass out to our clients.

Other:

Required

Anything else Ruff Day should know?

Use this space to provide any additional information you think may be helpful for Ruff Day's Dr. Misener to know.

I certify that I am a licensed veterinarian referring my patient, as described above, to Dr. Heather Misener at Ruff Day Veterinary Services for rehabilitation, acupuncture, and/or shock wave therapy. *

I am a Veterinarian.

I am NOT a Veterinarian (please visit the "Contact" page if you are an owner requesting an appointment for your pet).

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