Rehabilitation - Vet Referral - Aldgate Veterinary Practice

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This form should ONLY be used by veterinary surgeons and not by pet owners. If you are a pet owner and would like your vet to make a referral to us for this service, please complete this form.

A member of our client care team will contact your client directly to book an appointment. Please DO NOT use this form in an emergency/urgent referral, please contact us by phone on 01262 677269

If you are having problems submitting the form, please email rehab@aldgatevet.co.uk or call us on 01262 677269.

Referral details *

Hydrotherapy (clinical - underwater treadmill/pool/aquatic massage)

Chronic pain management

Physiotherapy

Unknown - I would like a call to discuss the most appropriate service for my patient

Owner's details

Full name *

Address *

Telephone *

Email address

Pet's details

Name *

Species *

Breed *

Pet's date of birth *

Sex *

Male

Female

Neuter status *

Neutered

Not neutered

Referring practice details

Referring practice name *

Referring practice address *

Referring practice telephone *

Referring practice email *

Name of case clinician

Clinical history summary and problem for which pet is being referred *

Current medications *

Company with which pet is insured (if applicable)

Veterinary consent

I certify that the above-named pet is under my care. In my opinion, this pet is in a suitable state of health to undergo the proposed rehabilitation treatment.

Veterinary surgeon signature:

Type name *

Date *

Clinical history upload

Please upload patient clinical history, laboratory results and any imaging relevant to the referral.

Choose upload document *

Choose File

Many thanks for your referral. A treatment report will be emailed to the case clinician following initial examination. Subsequent communication will occur following treatment cessation or if there are changes to clinical presentation during treatment.

Rehabilitation – Vet Referral