Virtual Veterinary Behavior Medicine Referral Form

Referral Form

Virtual Veterinary Behavior Medicine (VVBM) offers remote consultations for your clients to deliver specialty care straight to their home.
Prior to Scheduling

Prior to scheduling the virtual consult, the referring veterinarian is required to attest to the physical health of the pet and to provide details of a recent physical exam and any lab work. The referring veterinarian will also be consulted about prescribing and making medication changes throughout the patient's follow up window.
Appointments
- Appointments typically last 45-60 minutes.
- A written summary of the appointment and treatment recommendations will be emailed to the client and the referring veterinarian.
- Changes to the treatment plan can be made by email communication for a one month follow-up period after the appointment, as long as the referring veterinarian is involved in all communications and will take responsibility for any recommended medication changes.
- After the one month follow up period, any changes will require a recheck appointment.
- There will be NO phone call consultation between the client and the behavior clinician after the initial appointment. All follow-up contact between the client and behavior clinician must be conducted through email, with the referring veterinarian copied.
Scheduling
- Appointments are scheduled online at vvbm.vet
- Full payment is required at the time of scheduling.
- Referral is required prior to scheduling an appointment.
- A medical history, including physical exam notes and any lab work should also be submitted to info@vvbm.vet.
For the referring veterinarian:

Please fill out and sign below, affirming that you are willing to help implement a diagnoses and treatment plan for this client in consultation with the behavior service clinician. You will maintain the VCPR with this client and patient for the duration of the consulting relationship.
Practice Name*
Practice Phone*
Practice Email*
example@example.com
Client Name*
Client Phone*
Client Email*
example@example.com
Patient Name*
Patient Signalment*
Reason for Referral*
Referring veterinarian printed name*
Referring veterinarian electronic signature*

Clear
Date*

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Date
Should be Empty:

Referral Form

Prior to Scheduling

Appointments

Scheduling