Veterinary Consent Form for Therapies at Canine Pain Relief
Please fill this form out if you wish to refer your patient to Canine Pain Relief for Therapeutic Services


Canine Pain Relief
519-835-9449
info@caninepainrelief.ca
Kitchener, Ont.
Client's Name *
Your answer
Client's Phone # *
Your answer
Client's Email
Your answer
Patient's Name *
Your answer
Patient's Weight
Your answer
Patient's Breed, Colour, *
Your answer
Patient's Age *
Your answer
Patient's Gender *
Consenting Veterinarian *
Your answer
Clinic Name: *
Your answer
Clinic Phone # *
Your answer
Clinic Email *
Your answer
Reason for Referral/ Diagnosis *
Your answer
Diagnostics & Previous Treatments *
Your answer
Medical Problems of Patient *
Your answer
Medications/Supplements Patient is Currently Taking: *
Your answer
Requested Treatment
I am sending the following information/records (please forward any relevant information) *
Required
Other Comments/Questions:
Your answer
I have seen and examined the dog named in this form and confirm it is in suitable state of health for the above requested services *
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