Request for Level of Consultation and Participation Request for Level of Consultation and Participation

Maddox Veterinary Chiropractics – Chiropractic Service

Dr. Andrea Maddox, DVM, Certified in Animal Chiropractic by the

International Veterinary Chiropractic Association

 (931) 273-9599

REQUEST FOR LEVEL OF CONSULTATION and

PARTICIPATION FROM PRIMARY VETERINARIAN

TO: __________________________________________________________________________

       __________________________________________________________________________

THE PATIENT LISTED BELOW IS BEING SEEN AND TREATED WITH, AND ONLY WITH, CHIROPRACTIC CARE, BY DR. MADDOX, DVM., FOR SYMPTOMS RELATING TO THE FOLLOWING CONDITIONS:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

( ENCLOSED ARE COPIES OF THE INITIAL EXAMINATION AND FINDINGS. )

PLEASE BE AWARE THAT YOUR NAME AND/OR CLINIC NAME WAS GIVEN AS THE PRIMARY HEALTH CARE PROVIDER FOR THIS PATIENT.

PLEASE REVIEW THE FOLLOWING, CHECK THE APPROPRIATE BOXES, COMPLETE ALL REQUESTS, AND RETURN THE FORM TO ME.  THANK YOU.

o  The patient listed below is being seen in our clinic.

o  The patient listed below has been examined at this clinic for the conditions listed above.

o  Please call me as soon as possible to discuss this case.  I would like to be involved in all

     decisions concerning your chiropractic care.

o  Please send me a copy of your chiropractic treatment plan for review.

o  Do not send any additional information to me, only consult me if a traditional veterinary

      condition or emergency arises, if you need to alter your chiropractic treatment plan, or at

      the termination of treatment.

o  Please send copies of all of your chiropractic care for my files.

o  DO NOT TREAT THIS PATIENT WITH CHIROPRACTIC CARE, AS HIS/HER

      CONDITION,  IN MY OPINION, CAN ONLY WORSEN WITH THAT TYPE OF CARE.

ALL INFORMATION PERTAINING TO THIS PATIENT'S CONDITION (S) AND HEALTH HISTORY, INCLUDING, BUT NOT LIMITED TO, PREVIOUS DIAGNOSTIC TESTS, DIAGNOSES, TREATMENT, AND PROGNOSES ARE BEING FORWARDED TO

DR. MADDOX BY:

         o  Telephone, at 931-273-9599;

         o  Mail, at 218 Blue Bird Drive, Fayetteville, TN 37334

Signed by Veterinarian:___________________________________________________Date:____________

Client Name:________________________________Patient Name:_______________________

Species:__________________________Breed:________________________Age:____________

Signed by client________________________________________________Date:____________