Rehab Referral Form

Georgian Bay Veterinary Hospital

2 Concession Road 9 E
Perkinsfield, ON L0L 2J0

(705)245-1353

www.georgianbayvethospital.com

Physical Rehabilition Referral Form

To be completed by the referring veterinarian only


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Owner Information
spacer*Owner Name(s):
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Pet Information
spacer*Pet Name:
spacerBreed:
spacerSex:
spacerAge:
spacerWeight:
spacer*Rabies Vaccination:
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Referring Veterinarian Information
spacer*Referring Veterinary Hospital:
spacer*Referring Veterinarian
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Injury/Illness Information
spacer*Clinical Condition and Date of Onset
spacer*Treatment since Illness/Injury
spacer*Concurrent Issues/Relevant Medical History
spacer*Goal of Rehabilitation
spacerSpecial Instructions/Precautions
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Concerns or Contraindications
spacerCryotherapy (open wounds, sensory impairment, hypertension)
spacerHeat Therapy (heavily sedated, sensory impairment)
spacerHydrotherapy (fresh incision, wounds, skin infections)
spacerGait Training
spacerMassage (infectious disease, acute viral disease)
spacerTherapeutic Exercise
spacerOmega Supplement Recommendations
spacerGlucosamine recommendations
spacerOthers:
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