Referral/Delegation Form for Vets

Name of pet(s) being referred: *

Veterinary practice name:*

Referring practice's email address:*

example@example.com

Veterinary practice's 'phone number:*

Area CodePhone Number

Referring veterinary surgeon's name:*

First NameLast Name

Optional: Alternative (e.g. vet-specific) email address:

vetname@example.com

I am a Veterinary Surgeon, & this patient is under my care*

Yes

As per the RCVS Code of Conduct for Veterinary Surgeons guidance on referral/delegation, and with the understanding that I maintain the Duty of Care for this patient, I - the above-named veterinary surgeon - acknowledge my approval for the client and pet described above to be referred for behavioural assessment and treatment to: Linda Ryan BSc (Hons) Animal Behaviour and Welfare VTS (Behaviour, Oncology) DipAVN (Medical) KPA-CTP RVN CCAB, trading as Inspiring Pet Teaching.*

Yes

Client's name*

First NameLast Name

Client's email address:*

example@example.com

Client's 'phone number:*

Area CodePhone Number

Optional: Client's 'phone number(additional/alternative):

Area CodePhone Number

Client's address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Has this client given informed consent for behaviour referral, & sharing of their clinical history + all case-related details for the duration of the case being under my care?*

Yes

Pet's species & breed-type:*

Pet's sex & neuter status: *

Pet's age: *

Approximate date of referred pet's last clinic visit:*

Reason for clinic visit:*

Brief nature/details of the behaviour problem you are referring for, as you understand it?*

Approximate duration/date the behaviour problem was first noticed:*

Are you concerned re any kind of human safety risk, related to the patient's behaviour or the situation, that you feel I should be aware of (for me, or the client[s])?*

YesNo

Any acute or chronic details, comments or concerns you’d like to give regarding the patient's physical health status?*

Is the patient currently on any medication(s), or any type of vet-prescribed treatment?*

I have assessed this patient for pain:*

YesNo

Has this patient got any pain, or possible reason to have pain? Please give details of any concerns re-pain: *

Do you consider this patient to have any physical/medical causes, influences or confounders, which may impact or exacerbate the behavioural concern? This includes the potential effects of any medication or prescribed treatment? (Please give details)*

Has psychotropic medication been considered/prescribed for behavioural reasons?*

YesNo

Whilst always remaining within the remit of an RVN & CCAB, are you comfortable for the general concepts of behavioural medications being raised & discussed, as is clinically appropriate to this case? (Discussion of doses, schedules, specific medications, etc. & prescription of psychopharmacology, being respectfully referred back to you, the referring vet.)*

YesOther

Has surrender or re-homing been considered/discussed for behavioural reasons?*

YesNo

Has euthanasia been considered/discussed for behavioural reasons?*

YesNo

How does this patient behave when at the vet clinic?*

Is there anything else you would like me to know about this patient, the client, the home, or the situation? *

Would you like to discuss this case before I see the client/pet? (If so, please let me know and I will arrange to call you at a mutually convenient time)*

YesNo

Please attach the patient's clinical record (including summary medical history, details of any recent/relevant blood screens/specific organ function tests and assays, +/- purpose of any recent/relevant treatments, procedures or general anaesthesia, etc.):*

Browse Files

Optional: Please attach anything else you feel is relevant to the management of this case, from a behavioural point of view, e.g. supplementary documentation, a 2nd referred pet's clinical notes, or those of another animal that you deem important to the above-named case:

Browse Files

Tertiary level input from a Veterinary Behaviourist: On occasion, for specific cases in which behavioural medication may play a part, or where there may be confounding medical factors – and with client consent – do you give permission for Linda Ryan/Inspiring Pet Teaching Ltd. to collaborate with/request a case review from a Veterinary Behaviourist colleague? This is a peer-to-peer service, with all communication & case management going through Linda Ryan, and a copy of the report, with action points to consider in support of the case, being sent to your practice*

YesNoI would like to discuss this further, should the need arise in this case

Thanks so much!

If you have questions, please just ask: linda@inspiringpets.com - I shall be happy to help. And, for more info on Inspiring Pet Teaching, please visit www.inspiringpets.com, and like/follow our Facebook page.

This form/web-page & all of its content is intended for the recipient only. It is copyright 2020 Linda Ryan, trading as Inspiring Pet Teaching Ltd. Please do not reproduce or share any part of this form or its content. Thank you!

Behaviour Delegation/Referral Form for Vets