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CHAH Rehabilitation and Pain Management

Professional patient referral program

When you refer to our rehab department, you can trust that your patient will continue to be your patient.  Our rehab services will be an extension of your own practice.

Tailored rehabilitation plan custom to the need of your patient. Progress evaluations reported back to the referring veterinarian. If addition diagnostics are recommended, you can choose for them to be referred back to you.

Please provide all medical records pertaining to patient being referred for rehabilitation and all diagnostics that have been completed.

First Referring Veterinarian Name

First Name*

Last Name*

Phone*
First Referring Veterinarian Age Acknowledgment*
First Referring Veterinarian Date of Birth*
I certify that I am 18 years of age or older
First Referring Veterinarian Signature*
Second Referring Veterinarian Name

First Name*

Last Name*
Second Referring Veterinarian Date of Birth*
Third Referring Veterinarian Name

First Name*

Last Name*
Third Referring Veterinarian Date of Birth*
Fourth Referring Veterinarian Name

First Name*

Last Name*
Fourth Referring Veterinarian Date of Birth*
Fifth Referring Veterinarian Name

First Name*

Last Name*
Fifth Referring Veterinarian Date of Birth*
Sixth Referring Veterinarian Name

First Name*

Last Name*
Sixth Referring Veterinarian Date of Birth*
Seventh Referring Veterinarian Name

First Name*

Last Name*
Seventh Referring Veterinarian Date of Birth*
Eighth Referring Veterinarian Name

First Name*

Last Name*
Eighth Referring Veterinarian Date of Birth*
Ninth Referring Veterinarian Name

First Name*

Last Name*
Ninth Referring Veterinarian Date of Birth*
Tenth Referring Veterinarian Name

First Name*

Last Name*
Tenth Referring Veterinarian Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Referral Information:

• Hospital Name:

• Veterinarian Phone Number:

• Veterinarian Email: *
Client Information:

• Client Name: *

• Client Phone Number: *

• Client email: *
Patient Information:

• Patient name: *

• Patient breed:

• Patient age:

• Patient sex:
• Is patient fractious or infectious:*
No
Yes

Reason for referral (patient must have a diagnosis): *

Goals/expectations: *

Approved date to start rehab:
If additional diagnostics are recommended, how would you like us to proceed:*
Please refer back for diagnostics
Please proceed with internal diagnostics
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 In accordance with Texas Veterinary Board Rules, as the supervising Veterinarian, I have established a valid veterinarian/client/patient relationship and have determined that rehabilitation will not likely be harmful to this patient.


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