ITM’S VETERINARIAN
PRACTITIONER
REFERRAL INFORMATION FORM
2006
IMPORTANT NOTE: Please fill out this
form completely and accurately. It will
serve as background information for making referrals to you (essential for
inclusion in our practitioner guide) and will be utilized in developing statistics
about the practice of Chinese medicine in the U.S. Answer all questions on both sides; please write clearly or
type. Your listing in our practitioner
guide is free. If there are several practitioners at one clinic, have one
person fill out this form. We currently
have listings of approximately 100 veterinary practitioners. Even though you may have filled out a
previous form, we need this updated information to retain your listing (this
form is usually sent for updating every two years). The practitioner referral listing is mailed to individuals
seeking this type of health care for animals and is posted on ITM’s website
(www.itmonline.org).
Your Name, with any credentials you wish to have
listed (e.g., D.V.M., L.Ac.):
__________________________________________________________________________
Clinic
name (if any), complete address (primary site), and primary contact
information:
(see reverse for listings of multiple
practitioners or multiple sites)
Clinic name: _________________________________________________________________
Address: ___________________________________________________________________
City: _________________________ State: _______________________ Zip: ____________
Primary phone: ________________ Fax: ________________ E-mail: ___________________
The
school(s) where you received your professional training and received degrees/diplomas:
(mention names of professional schools granting
degrees)
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
Type
of animal, size of animal, & specialties for which you have considerable
experience:
(list in order of priority)
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
Diagnostic
methods (e.g., traditional Chinese, modern lab tests, etc.):
(in approximate order of emphasis or frequency
of use)
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
What are the main
therapeutic methods you employ? (modern medicine, acupuncture, Chinese herbs,
Western herbs, specific techniques, etc.):
(in approximate order of emphasis or frequency
of use)
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
Years in practice (with
licensing): _______________________
Fees for a typical office visit (if several fees
apply, please list):
Initial visit fee: $______________ Typical duration: ________________ (minutes)
Follow up visit fee: $___________ Typical duration: ________________ (minutes)
MULTIPLE-PRACTITIONER
FACILITIES
Names of individuals working in the same clinic;
include their medical licensing :
1._________________________________________________________________________
2._________________________________________________________________________
3._________________________________________________________________________
SURVEY QUESTIONS
What is the most frequently used forms of herb
prescriptions; list in order of frequency, items such as teas, patent pills, capsules, tablets,
tinctures, granules, others (specify; do not include homeopathics in this
section):
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
How many professional
books on Chinese medicine are in your library? _______________________
How many journals about
Chinese medicine do you subscribe to? ___________________________
Please list journals:_____________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
How many hours of
continuing education do you attend in a year? ___________________________
Are you a current member
of ITM’s START Group? ____________________________________
THANKS FOR FILLING OUT
THIS FORM.
Mail promptly to:
ITM
2017 SE Hawthorne
Portland, OR 97214