Veterinary Consent Form for Therapies at Canine Pain Relief
*Please note that by filling out the below information, the referring veterinarian consents to rehab therapy for the patient listed. The veterinarian is aware that all therapies will be provided by or under the supervision of a Certified Rehabilitation Practitioner.

Please be specific in what you would like treated for your patient. We cannot and will not treat areas that are not detailed in this form. 

There are no services at Canine Pain Relief that take the place of primary veterinary care. 

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Client's Name *
Client's Phone # *
Client's Email
Clients Address
Patient's Name *
Patient's Weight
Patient's Breed, Colour, *
Patient's Age *
Patient's Gender *
Consenting Veterinarian *
Clinic Name: *
Clinic Phone # *
Clinic Email *
Reason for Referral/ Diagnosis- Please indicate what you would like treated. Eg. for laser, indicate which areas/joints. 
**We can only treat what is specifically referred to us** We do not diagnose here. 
 *
Diagnostics & Previous Treatments *
Medical Problems of Patient *
Medications/Supplements Patient is Currently Taking: *
Requested Treatment *
Required
I am sending the following information/records (please forward any relevant information) *
Required
Other Comments/Questions:
I have seen and examined the dog named in this form and confirm it is in suitable state of health for the above requested services *
Submit
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