New Client Form

Please fill out the form below with as accurate information as possible.

If you are not a veterinary practice, please just fill out the client, animal and veterinary practice information sections. Our team will contact your veterinary practice to complete all other relevant sections.

Veterinary Referral Form For Massage

Client Details

First name

Last name

Email

Phone

Address & Postcode

Animal Details

Name

Breed

D.O.B / Estimated Age

Fur Colour

Sex

Weight

Fully Vaccinated

Insured

Yes

No

(If Yes) Insurer Name

Veterinary Practice information

Veterinary Practice

Referring Veterinarian

Practice Address & Postcode

Phone

Email

Client History / Referral Information

Current Reason for Referral

Investigations / Finding

Current Medications

Pre-existing Conditions

Any known Lumps, Bumps or Skin Issues

Specific patient requirements (Behavioral, Physical)

Declaration: This client is a patient under my care and I have conducted a full medical health check and examination prior to referral for massage therapy. I approve this animal for massage therapy and agree they are fit to receive treatment from Canine Comfort Rehab.

Signature

Signature field is empty.

Print Name

Practice Stamp

Signature field is empty.

Date

Day

Month

Year