Please Note: This referral form must be signed by the
veternarian before treatment can commence
Owners Details
Name:
Address:
Tel:
Mobile:
Email:
Animal Details
Name:
Breed:
Age:
Insurance company:
Colour:
Date last vax:
Sex:
Date last worm:
Policy No:
Veterinary Details
Veterinary surgeon:
Practice:
Address:
Tel:
Summary of injury or condition:
Current / recent medication:
Precautions to treatment:
Progress reports will be provided by TCHC:
Should TCHC contact you prior to rehab treatment for case discussion? YES / NO
I certify that the above animal is under my care.
In my opinion, rehabilitation or hydrotherapy is indicated for this animal.
Veterinarian Signature:
Date:
I am the owner of the above animal and I consent to treatment as discussed at TCHC.
Owner Signature:
Date:
Would you like TCHC to contact you to arrange an appointment? YES / NO
Please foward to: TCHC by fax: 01777 248695 or post: Cocking Lane, Treswell, Retford, Nottingham, Notts. DN22 0JD
Please tick here if you need anymore referral forms
Specialists in Canine Hydrotherapy, Boarding Kennels and Grooming Parlours in Retford, Nottingham, Notts.
Treswell Canine Hydrotherapy Centre. Cocking Lane, Treswell, Retford, Nottingham, Notts. DN22 0JD
Tel: 01777 248695 | Mobile: 07870 523192
