Acupuncture Referral Form

Please complete the form below to request a visit with Dr. Kim Mitchell DVM CVA

    All fields are required.

    Client's First Name:

    Client's Last Name:

    Email Address:

    Phone Number:

    Pet's Name:

    Name of Referring Veterinarian:

    Reason for Referral:

    Please List Any Current Medications

    Medication 1

    Name of Drug:

    Route:

    Dose in mg/kg:

    Frequency:

    Medication 2

    Name of Drug:

    Route:

    Dose in mg/kg:

    Frequency:

    Medication 3

    Name of Drug:

    Route:

    Dose in mg/kg:

    Frequency:

    Medication 4

    Name of Drug:

    Route:

    Dose in mg/kg:

    Frequency:

    What Treatments Have You Tried?:

    Do You Have A Laser Machine At Your Office?:

    Please Upload Any Recent Lab Work & Diagnostic Imaging:

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