Veterinary Referral Form

Veterinary Referral Form
To work with behaviour problems effectively we need to ensure the dog in question is in good health, as behaviour change is commonly a symptom of pain or illness. As such, all of my behaviour clients must obtain a referral from their veterinarian.

It is recommended, when considered potentially relevant, that routine blood tests (including a thyroid panel) and a stool screen are carried out. If the dog appears to have any structural issues (even if only minor) a trial of non-steroidal pain relief may allow discomfort as a potential motivator for the behaviour problem to be ruled out.

If you require references related to the above, please don’t hesitate to ask. I value your expertise and experience and will gladly receive a referral without the above being done if you don't feel they are required. However, if the cue for the behaviour cannot be identified, application of methods proves ineffective and problem solving reaches a dead-end, I may refer the owner back to you.

The methods I use are science-based and kind. In-depth assessments are carried out, exploring the dog’s history and behaviour.
Veterinary Surgeon Details
Referring Veterinarian*

First NameLast Name
Practice Address*

Address Line 1

Address Line 2

Town/CityCounty

Postcode
Practice Tel. No.*
Please enter a valid phone number.
Contact Email for Vet/Practice*
example@example.com
Client details
Client's Name*

First NameLast Name
Dog's Name*
Dog's Breed*
Dog's Age*
Dog's Sex*

MaleFemale
Neutered?*

YesNo
Description of presenting problem (if known)
Date first noticed by client (if known)

DayMonthYear
Date
If you have any concerns about the dog's health that you feel may be contributing to the behaviour problem in question, please note them here.
Please upload a copy of the patient's full clinical history here. If you are unable to do so for any reason, please send it to info@perfectly-canine.com instead.

Cancelof
I hereby acknowledge my approval for the client described above to be referred for behavioural therapy to Rosy Skilton.
Signed (Referring Veterinary Surgeon)*

Powered by Jotform SignClear
Print Name*

First NameLast Name
Date*

DayMonthYear
Date
Thank you for filling in this referral form. Once I have met with the client you will receive a summary report with my assessment of the case, and I will keep you updated as to the patient's progress.

If you have any questions at all, please don't hesitate to contact me by email at info@perfectly-canine.com or by telephone at 07597 650726.

Rosy Skilton

Provisional CAB Member of the APBC

FABC Candidate Member

ADip in Applied Animal Behaviour
Should be Empty:

Veterinary Referral Form

Veterinary Surgeon Details

Client details