Underwater Treadmill Referral Form (To Be Filled Out By Your Veterinarian)

We are happy to underwater treadmill therapy for your patients. When therapy is done under the supervision of a veterinarian (like our facility), it is often covered by insurance. Underwater treadmill is exercise and exertion, so if you have concerns about this pet’s vascular system, please talk to your client about working that up prior sending the pet to us. If your client decides after starting with underwater treadmill therapy that they want to come for a full rehabilitation evaluation, we will keep you informed of the change of VCPR for this treatment.

"*" indicates required fields

Client name:*

First name: Last name:

Patient name:*

Dog

Cat

Other

Patient age:*

Patient breed:*

Any behavioral concerns we should be aware of?*

Diagnosis and reasons for underwater treadmill therapy:*

This is a healthy patient seeking underwater treadmill therapy for conditioning or weight loss only.

Release of liability:

By my signature I certify that I have a Valid Veterinary Client Patient relationship with this client and pet and have examined this pet within the last year.

By my signature I am accepting that I am the veterinarian of record for this referral and understand that the doctors at Healing Arts Animal Care will not be treating or diagnosing this pet. The pet will be treated by a highly trained veterinary assistant or technician in areas I indicated above. If the staff feels other areas need treatment, they will call or email me to amend the prescription.

By my signature I indicate that I understand this is a prescription for a treatment under my veterinary license. Just as a prescription for a medication that goes to a human pharmacy, this is a prescription executed by the staff at Healing Arts Animal Care.

By my signature I certify that, to my knowledge, this pet has no known bone neoplasia, infectious disease, or vascular compromise.

I certify that my electronic signature here is as valid as a written signature.

Signature*

Date*

Veterinary Licence*

(we ask for your license number to prevent forgery of this document)