Veterinary Referral Form

In accordance with the Veterinary Surgeons Act of 1966 and the Veterinary Exemption Order of 2015, consent for treatment will need to be obtained from your veterinary surgeon. This ensures that there is a good communication pathway between the professionals that will be providing ongoing care.

Please forward the link to this page to your vet to complete.

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Veterinary Practice Name

Name of Referring Vet

First

Last

Telephone Number

Owner's Name

Owner's Telephone Number

Owner's Email

Owner's Address

Animal's Name

Breed

Age & Sex

Relevant Medical History - case notes can be emailed to hello@jennapayne.co.uk

Current Medication

Any Other Information

Insurance Company Details (if referral is part of a claim)

Do you require a copy of my insurance policy?

This will be emailed to you on the address provided at the start of this form.

Do you wish to be emailed a copy of the treatment report(s)?

Declaration

I consent for the animal declared in this form to be treated with McTimoney veterinary chiropractic techniques and massage therapy by Jenna Payne, McTimoney Veterinary Chiropractor. I confirm that I have detailed any known conditions that may impact treatment, in particular any relative contraindications where treatment should be adjusted.