May 26, 2019

Veterinary referral

Please note that none of the client information you place on the referral form will be used for marketing purposes nor shared to any other person or organisation.

Physiotherapy Treatment Veterinary Referral/Consent Form for Classic Physiotherapy

This form is intended for use by referring veterinarians ONLY. Upon completion and submission an email will be sent to the referring vet as confirmation.

Vet Referral Form

* indicates required field

Referring Veterinarian Details:

Referring Veterinarian Name*

Vet email for physiotherapy reports and confirmation email to be sent to*

Referring Veterinarian Practice*

Referring Veterinarian Address*

Referring Veterinarian Telephone:*

Owners Details:

Owners Name:*

Owners Address:

Owners Telephone:*

Owners Email:

Pet Insurance Company

Details of Animal being Referred:

Type of Animal:*

Animals Name:*

Animals Age:*

Animals Breed:*

Animals Sex:*

Neutrered?*

Veterinary Referral Details

Reason for Referral:*

Relevant Medical History/ Special Instructions/ Precautions:

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Veterinary Consent/Recommendation for Physiotherapy Referral

I recommend / consent this animal receives a physiotherapy assessment and any appropriate treatment. I understand, in making this referral, I am not responsible for any physiotherapy assessment or treatment given, and the provision of professional indemnity insurance for physiotherapy treatment is the responsibility of Nycky Edleston. I understand that I will be kept informed of said treatment.:*

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Proprioception is a combination of balance, joint position sense, and body awareness. Part of this is derived from sensory apparatus within the muscles, tendons, ligaments and joints. When any of these areas are damaged, in pain or recovering from injury/surgery, the sensory apparatus are damaged and need proprioceptive stimulation to recover and do their job again. Physiotherapy treatment works to gain proprioception. Good proprioception leads to correct use of limb and body. Athletes benefit from fine tuning proprioception to help prevent injury.