Laser Therapy Referral Form (Online)

Referring Veterinarian Name *

Referring Clinic / Hospital Name *

Veterinarian Phone Number

Owner Name *

Owner Phone Number

Patient Name *

Patient Species

Canine
Feline

Patient Breed

Patient Age

Selected Value: 0

Diagnosis

Precautions and Contraindications

There can be potential adverse effects laser therapy can have on cancerous cell growth. Have there been any oncological changes or concerns for this patient that should be considered during laser therapy treatment? If so, please describe below.

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