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Patient Forms

Here you’ll find the Acupetvet Client Referral Form + Nutrition & Food Log

Learn About Acupetvet

Client Referral Form

- Step 1 of 5

I am filling this form out as a referring veterinarian or veterinarian office *

Yes, I'm a referring veterinarian
No, I'm looking to schedule an appointment for my pet

DO NOT FILL THIS FORM OUT

Rather, contact us at acupetvet.net/contact/ to schedule an appointment for your pet.

Sincerely,
Acupetvet Staff

Client Name *

Contact Phone

Client Address

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name *

Pet's Date of Birth

Age/ Please let us know if approximate

Breed

Primary Veterinarian and Clinic *

Sex *

M
M/N
F
F/S

Rabies Vaccine Due Date *

Reason for Referral

This is a Referral For Initial Rehabilitation Consult & Treatment. Initial consults are done for rehabilitation and acupuncture appointments.

Veterinary Diagnosis (please fill out completely) Primary Concern/Problem/diagnosis Recent diagnostics , surgeries *

Other diagnoses and comments ( including possible contraindications, aggressive tendencies, muzzle, etc) *

write none if none

History of Seizures? *

Yes
No

If Yes, please explain (when, frequency, medication,etc)

History of Cancer? *

Yes
No

If Yes, please explain (diagnosis,date,diagnostics)

Food Allergies? *

Yes
No

If Yes, please explain

Current Medications or Supplements Pet Is Using

Pet records *

I am able to upload pet records now
I prefer to email records at a later time

Please Email Pet Records To:

Dr. Tasha Wilson at info@acupetvet.net to begin the intake process.

Sincerely,
Acupetvet Staff

Please upload pet records:

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload any additional information for Dr. Tasha Wilson.

Referring veterinarian's signature *

Please e-sign your name

Name of Veterinarian *

Please provide veterinarian's name

Name of Clinic *

Email Address and Phone Number *

Please provide contact information for us to reach you if there are any questions.

Veterinarian listed approved this form (vet needs to approve-this is needed for referral) *

Yes
No

Person who filled out referral form and title. If you are not the veterinarian you acknowledge that by signing this form you are confirming that authorized veterinarian has okayed and approved this referral *

Please e-sign your name

Date *

Insert date of signature

Print Client Referral Form

14 Littleworth Rd, Dover, NH 03820. Click here for a map to our location

Hours: Mon. 9-6, Tue. 9-7, Wed. 10-2, Thur. 9-6, Fri. 9-4. Hours may change based on appointment availability and Holidays.

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