Referral  form  –  Acupuncture  4  Pets  Ltd  –  Veterinary  acupuncture  treatment   Please  complete  and  return  to:  [email protected]    

Date  

 

 

Information  about  referring  vet:   Referring  Veterinary  Surgeon     Referring  Veterinary  Practice     Address   Street/Building   City/Town   County   Post  code   Telephone   eMail  address  

               

 

Information  about  client  and  pet:   Name  of  client     Address   Street/Building   City/Town   County   Post  code   Telephone   eMail  address   Name  of  your  pet    

               

About  the  pet:  

Species   Breed   Condition  for  treatment  

Other  conditions     Medications  

                       

Data  Protection  and  Privacy  Statement:    By  completing  this  form  you  consent  that  Acupuncture  4  Pets  Ltd  may  use  the  information  provided   and  store  the  information  both  electronically  and  on  paper.    You  also  consent  that  Acupuncture  4  Pets  Ltd  may  contact  you  and  the  veterinary   surgery  specified  in  relation  to  the  data  provided.    The  information  provided  by  you  will  be  used  for  the  management  and  administration  of   cases  relating  to  the  pets  specified.    Unless  you  opt  out  of  marketing,  the  information  you  provide  may  be  used  for  the  purposes  of  marketing   relevant  Acupuncture  4  Pets  Ltd  services  in  the  future.  Marketing  may  be  via  post,  email,  telephone  and/or  text  message.    You  may  opt  out  of   marketing  by  sending  an  email  to  [email protected].    Other  than  when  legally  obliged  to  do  so,  Acupuncture  4  Pets  Ltd  will  never  share   your  information  with  another  third-­‐party  without  your  consent.  

© Acupuncture 4 Pets Ltd | Co. No. 09256187 registered in England & Wales | 07876 289 941 | [email protected]  

 

Referral form - Acupuncture 4 Pets Ltd.pdf

Address Street/Building. City/Town. County. Post code. Telephone. eMail address. Information about client and pet: Name of client. Address Street/Building.
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