Veterinary Referral Form for Alternative Medicine – Acres Animal Hospital

Referral Form

Thank you for referring your patient for chiropractic and/or acupuncture and/or traditional Chinese herbal medicine treatment. To help me assess your patient's problem, please complete the information below. A referral relationship will be respected. Thanks, Laura Lee

Referring Veterinarian
Referring Veterinarian*
First Last
Veterinary Hospital*
Phone*
Email*
Patient Information
Client's Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*
Patient's Name*
Species*
Breed*
Date of Birth*
Date Format: MM slash DD slash YYYY
Sex*
Alternative Medicine Referral Information
Dr. Laura Lee offers acupuncture, laser acupuncture, traditional Chinese herbal medicine, and veterinary fascial therapy (soft tissue chiropractic).
History of Current Problem
Previous Diagnostic Tests and Results
Previous Therapy or Treatment and Results:
Other Medical Problems, Medications, and Supplements:
Other Concerns:
Medical Records
Drop files here or

Accepted file types: pdf, jpg, jpeg, png, gif, zip, dicom.
Medical records, radiographs, and laboratory results can be attached here. Pdf, jpg, png, gif, zip, dicom file formats are permitted with size up to 6 MB. For large files, please send to acres@ns.aliantzinc.ca.

Monday	12:00pm – 6:00pm
Tuesday	12:00pm – 6:00pm
Wednesday	12:00pm – 6:00pm
Thursday	12:00pm – 6:00pm
Friday	12:00pm – 6:00pm
Saturday	Closed
Sunday	Closed
Closed Holidays

Referral Form

Referring Veterinarian

Patient Information

Alternative Medicine Referral Information

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