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Veterinary Medical Clearance and Referral Form

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Veterinarian Referral for the Provision of Consultation in Physical Therapy


Animal Patient Name


Client Name(s)

Client Contact Information








Goals for Physical Therapy


Date of Follow-up with Referring Veterinarian


Veterinarian Name

Hospital Name




I am referring this animal patient to EmpowerPhysioPeT for physical therapy consultation with veterinary medical clearance. Veterinary medical clearance means that the veterinarian has previously examined the animal patient and has provided a differential diagnosis, if appropriate. The veterinarian has cleared the animal for physical therapy.


Referring Veterinarian Signature

Date of Referral


Please attach any further pertinent medical history. EmpowerPhysioPeT will contact the referring veterinarian to discuss this case prior to the initial consultation and as appropriate throughout the course of care. Please indicate your preferred method of communication—telephone, email, or fax.


EmpowerPhysioPeT does not provide veterinary medical advice, evaluation, examination, assessment, or treatment. EmpowerPhysioPeT provides physical therapy consultation via Massachusetts Statute (MA ST) 112 § 58 in which, “Any specialist in the health or zoological field may be called in for consultation in these special fields by a veterinarian licensed in the commonwealth and may collect a reasonable fee for such consultation.”