Veterinary Referral Form

Integrative Medicine Consult

Integrative consults are best suited to:

  1. Patients that are not currently responding to solely conventional
    drug-based medicine for chronic medical conditions (ex: Skin and ear issues, gastrointestinal concerns, behavioral issues etc)
  2. Pet owner’s who are seeking complementary or integrative support for their pets.
  3. Veterinarians looking to offer multi-modal evidence-based support to their patients through collaborative team work

    Name of Referring Veterinarian:

    Veterinary Clinic:

    Vet. Phone

    Vet. Email:

    Owner Name:

    Owner Phone:

    Owner Email:

    Pet Name:

    Breed:

    Age:

    Previous vaccine reactions?

    Previous reactions to medications (please list these)

    Current diet if known

    How does the pet respond to veterinary visits?

    List of Current Medications:

    List of Medical Conditions:

    Additional information or comments:

    Please attach any recent lab work and radiology reports (within last 2 years)





    Thank you for submitting to our clinic for an integrative consultation. Our team will be in contact with the pet owner to arrange for an appointment.

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      London Integrative Veterinary Services

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