New Customer Registration Form

Veterinary Behaviourist Referral Form

Thank you for referring to Sussex County Dog Training, please fill in the form to refer your client.
Referring Vet:
Veterinary Surgeon Name*

First NameLast Name
Vet Practice Name*
Vet Practice Address*

Street Address

Street Address Line 2

TownCounty

Postcode
Practice Phone Number*
Practice Email Address*
example@example.com
Is this referral urgent?*

UrgentNon-Urgent
Date Form Completed*

MonthDayYear
Date

Information About The Patient:
Dog's Name*
Age Of The Dog Currently*

YearsMonths
Dog's Breed*

PedigreeSingle Cross (two different breeds)Multiple Cross (more than two breeds)
Dog's Breed*
Please provide details*
please give details
Sex and Neuter Status*

Male - EntireMale - Neutered/Chemically CastratedFemale - EntireFemale - Neutered
Is the dog on any current medications/supplements*

YesNo
If Yes, Please Name Them and Dosages
Known Current Medical History*

Cancelof

Dog Behaviour Consultation
Please describe the nature of the behaviour that is causing concern, including how it is impacting the client.*
How long has the behaviour been present and the age of the dog?*
Has the client considered euthanasia?*

YesNo
Has the client considered rehoming?*

YesNo
In cases of aggression, has the dog bitten?*

YesNo
If aware of a bite, please provide any known details.
Please confirm if the owner has provided consent for the clinical history of the above mentioned pet to be disclosed to the veterinary behaviourist for the purpose of a behavioural referral.*

Yes, owner has given consentNo, owner has not given consent
On completion of the consultation a written report will be provided to both you and the client.
Should be Empty:

Veterinary Behaviourist Referral Form