REFERRAL FOR SMALL ANIMAL MASSAGE

I, _____________________________, (owner) hereby request authorization for a Veterinary Referral for the massage care of patients:

1)                                                        3)

2)                                                        4)

I understand that massage, though not specifically addressed by the Texas Administrative Code, could be considered under the state law to be an alternative (nonstandard) therapy.  Further, I request for the massage services to be provided by Sarah Dow SAMP.

Owner __________________________________

_____________________________________________________________________________________________________________

I, _____________________________ (referring Veterinarian) in compliance with Rule §573.12 have performed the following tasks:

• Established a valid veterinarian/client/patient relationship;
• Examined the animal(s) to determine that massage will not likely harm the patient;
• Obtained a signed acknowledgment by the patient’s owner (see above) that massage could considered under state law to be an alternate (nonstandard) therapy and this copy has been placed in the animal(s) file.

Therefore, I hereby authorize Sarah Dow SAMP, to provide massage as desired by the owner for the patient(s) identified above.

______________________________                 ________________________

Referring Veterinarian                                              Date

Name: _______________________________________                   

Address: _____________________________________

Telephone: ___________________________________

Fax: _________________________________________