Vet Referral Form

Thank you for your referral. Please fill in the online form below, or if you prefer, download the PDF version here and email the completed form plus clinical history and any pathology reports to:

info@vetdermspecialists.com.au

Veterinarian*

Practice*

Practice email Address*

Phone

YesNo

First Name*

Surname*

Email Address*

Phone*

Residential Address

Street Address

City

Postal / Zip Code

Patient Name*

Species

Breed

Weight (kg)*

Age (years)

or Date of Birth

Sex

Please describe:

Referral Urgency:*

Urgency

Brief History:

Non-dermatological Diseases:

Additional Information:

Such as pet’s temperament, comments, or special requests.

Please upload patient medical records below, including all previous blood monitoring, biopsy, and culture results. Alternatively, records can be emailed to: info@vetdermspecialists.com.au

Maximum number of uploaded files is 10. Maximum individual file size is 15Mb. Please email info@vetdermspecialists.com.au regarding files in excess of these limits.

Files Uploaded

Referring Veterinarian

Client Details

Patient Details

Clinical History

Medical Records

Bee & Wasp Anaphylaxis Referral

Summary of Anaphylactic Episode

General Health