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Practice Name *

Practice Telephone Number *

Practice Address *

Referring Vet Name: *

Practice Email *

Client Name *

First

Last

I Diagnosis Number

Client Address *

Client E-mail

Client Telephone *

Pet Name *

Species *

Age *

Sex *Male EntireMale NeuteredFemale EntireFemale Neutered

Diagnosis *

Current medication including dose and frequency

Any questions/concerns regarding this patient being a suitable patient for acupuncture/myotherapy? *

I consent to Sarah Bignell-Howse, performing Myotherapy Treatment (soft tissue manipulation, and other massage techniques including Passive Movement Exercises) for soft tissue, specifically muscular conditions, on the above named pet *

• Yes
• No

I consent to Sarah Bignell-Howse using acupuncture if appropriate. *

• Yes
• No

Signed *

MRCVS

Date *

Submit

Details of Veterinary Surgeon and registered Galen Myotherapist® Requesting Consent:

Name: Sarah Bignell-Howse BVetMed, MRCVS, GP Cert (SAM)
Mob: 07944 902412                                 
Email:  sarah@mettapetclinic.co.uk

RCVS number 6199663

Registered Member of C.A.A.M. Registration number: 270119

Associated British Veterinary Acupuncture member: 37224

Professional Indemnity and Public Liability Insurance Policy Details: Veterinary Defence Society