Laser Therapy Referral Form

Laser Therapy is a non-invasive, drug-free treatment that uses infrared light to help reduce pain, decrease inflammation, and support faster healing. It can be recommended for wounds, surgical recovery, arthritis, joint and muscle pain, and other chronic conditions. If you’d like to learn more about how laser therapy works, click here.

REFERRING VETERINARIAN INFORMATION

Clinic/Hospital Name *

Clinic/Hospital Phone Number *

Clinic/Hospital Fax Number *

Clinic/Hospital Email *

Name of Referring Veterinarian *

CLIENT INFORMATION

Full Name *

Name of secondary contact and/or spouse

Address *

City *

Province *

Postal Code *

Phone Number*

Email Address *

PATIENT INFORMATION

Patient's Name *

Age *

In months/years, or birthdate

Species *

Breed *

Colour / Markings *

Sex *

Weight *

In kg

Vaccine Status *

REQUIRED DOCUMENTATION / INFORMATION

Primary diagnosis/concern and clinical signs *

Duration of condition *

Current Medications *

Previous laser therapy history *

Treatment goals (pain management, wound healing, mobility support, etc.) *

Upload Medical Records *

Preferred next step *

Additional Information / Comments:

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *