ITMíS 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 ITMís 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 asteas, 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 ITMís START Group? ____________________________________

 

THANKS FOR FILLING OUT THIS FORM.

Mail promptly to:

ITM

2017 SE Hawthorne

Portland, OR 97214