Acupuncture & TCVM Referral Request

Thank you for your interest in acupuncture and Traditional Chinese Veterinary Medicine (TCVM) services at Ball-Chatham Veterinary Services.

Please complete the form below so our team can learn more about your pet and determine the appropriate next steps for scheduling.

Acupuncture & TCVM Referral Request

First name*

Last name*

Email*

Phone*

Preferred Method of Contact

Phone

Text

Pet's Name*

Species*

Dog

Cat

Breed*

Age or Patient Date of Birth*

Sex*

Intact Male

Neutered Male

Intact Female

Spayed Female

Who is your pet's primary veterinarian?*

Veterinary Clinic Name*

Veterinary Clinic Phone Number*

What would you like acupuncture or TCVM to help address for your pet?*

Has your pet been diagnosed with a condition related to this concern?*

Yes

Unsure

Please list any current medications, supplements, or treatments your pet is receiving.*

Upload Medical Records or Diagnostics

For pets seeking acupuncture-only services, Ball-Chatham Veterinary Services may need to communicate with your pet's primary veterinarian before beginning treatment. Do we have your permission to contact your pet's primary veterinarian?*

Yes, I give Ball-Chatham Veterinary Services permission to contact my veterinarian and obtain approval for acupuncture treatment.

No, please contact me before communicating with my veterinarian.

Is there anything else you would like our veterinary team to know about your pet?

I understand that submitting this form is an appointment request and does not establish a VCPR or guarantee that acupuncture or TCVM is appropriate for my pet. BCVS will review my information and contact me regarding next steps.*

I have read and understand the statement above.

WE DO NOT ACCEPT CARE CREDIT.
Accepted forms of payment include: cash, check, debit or credit

10659 Warrington Road, Pawnee, IL • (217) 498-0363

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