Physical Rehabilitation New Patient Questionnaire - Veterinarian Referral
Thank you for referring your client for Physical Rehabilitation at Windsor Animal Hospital! The information provided in this form is greatly appreciated and will expedite communication between our hospitals and your clients consultation with us.

We will make every effort to ensure any medical care your patient needs is performed at your facility. Occasionally we will recommend changes in pain medications, additional diagnostics or therapies as they relate to the physical rehabilitation findings and we will communicate this to you directly. We want to foster a collaborative approach for patient care and client satisfaction. If you have any concerns at any time please don't hesitate to contact us.

Sincerely,
- Kristen Hagler RVT VTS (Physical Rehabilitation) CCRP CVPP OACM CBW
Integrative Medicine Department Director

Email address *
Veterinary Facility *
Please include your preferred method of contact, we will be using this information to send progress reports
Your answer
Primary Care Provider Name *
Your answer
Pet's Name *
Your answer
Client's Full name (First Last) *
Your answer
How did you hear about us? *
Your answer
Have diagnostics been performed within the past year that may relate to the pets condition? *
Diagnostics include ultrasounds, radiographs, bloodwork, etc. Please include specific information that may relate to the pets rehabilitation condition.
Your answer
What specific medical condition would you like to address with rehabilitation? *
Examples: degenerative myelopathy, intervertebral disc disease, osteoarthritis, etc.
Your answer
Does the pet have a condition that may affect rehabilitation therapy outcome and treatment planning? *
e.g. Cushings, Seizure disorder, Fear/Anxiety Syndrome, CHF, etc
Your answer
What therapies/modalities are you specifically recommending for this patient? *
Required
Are you performing any therapies for this patient at your hospital that we should be aware of? *
Required
In the space below, please include any other information that was not addressed in the questions above.
Your answer
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