For referring vets

Referral form

Please complete this form to refer a patient to Beyond the Vet Clinic for veterinary acupuncture and/or therapeutic laser therapy. You can submit it online below, or print a copy to complete by hand.

Please also email a copy of the patient’s recent clinical history to hello@beyondthevetclinic.com — and, for chronic-pain referrals, recent bloods and any relevant imaging (DICOM preferred).

Client details

Name *

Email *

Contact number

Town

Post code

Address

Pet details

Pet’s name

Breed

Sex & neuter status

Age / date of birth

Client consent

I confirm the information provided is accurate and complete to the best of my knowledge, I agree to the terms of business, and I consent to the sharing of relevant clinical information for my animal’s care. *

I consent to photographs and/or videos of my animal being taken during appointments, which may be used for educational or promotional purposes (including social media). No identifying personal information will be shared without my explicit permission.

Client name (signature) *

Date

Veterinary practice details

Practice name

Veterinary surgeon

Contact number

Practice email

Reason for referral

Chronic pain referral

Acupuncture referral

Pain history

Diagnosis

Weight (kg)

Current medications

Referring vet name (signature)

Date

For acupuncture-only referrals, by submitting this form the referring veterinary surgeon confirms there are no known contraindications to acupuncture in this patient.