Providing professional rehabilitation services for the canine athlete, working dog and family pet

CANINE REHAB Saskatoon

Referral Form

Dear Veterinarians,  please feel free to use this referral form, you can print it, or just refer by email to caninerehab@gmail.com with the pertinent info below.  Thanks!

CANINE REHAB Saskatoon

 Theresa Ziegler BScPT Diploma in Canine Rehabilitation

Email: caninerehab@gmail.com

Phone: (306) 220-0802

Fax: (306) 649-0762

Referral Form

Owner's name:

Address:                                                                                     Postal Code:

Phone:                                                                                        Cell:

Dogs Name:

Sex:            M       MN      F        FS                                           Date of Birth:

Breed:                                                                                         Colour:

Referred For:  Rehabilitation therapy program (applies to injured, post-surgical, arthritic, musculoskeletal and neurological cases).  Canine Athlete Sport examination and program (healthy dog for sport and conditioning assessment)   Please provide diagnosis and pertinent medical history of condition afflicting the above mentioned patient:

Surgical and/ or other procedures performed and date(s):

Medications:

Any concerns of contraindications to rehabilitation therapy to the above mentioned patient?

Veterinarian's name (print):_______________________   Veterinarian's signature:__________________________   Clinic:________________________________________   Date:_________________________________________