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About
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Vet Referral
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Fill out the form below to request a quote. I will get back to you to arrange a session.
Text me to make an appointment at (613) 799-2728, or complete the form below.
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Referral Form
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RDVM Name / License
*
Clinic Name
*
RDVM Email
*
Client Name
*
First
Last
Client Email
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Client Phone Number
*
Patient Name
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Patient Species
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Canine
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Presenting Complaint - Diagnosis
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Submission
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SUBMISSION OF THIS FORM hereby refers the aforementioned client to Nancy Couillard (the "Veterinary Technician Specialist in Physical Rehabilitation") and agrees to provide indirect supervision to the Technician relevant to this engagement, the costs of which shall be borne by the Animal Owner. A report will be provided following the initial consultation, as well as after each visit within three business days. If there is anything noted of any concern, the client will be referred back to the regular veterinarian for a follow-up.
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