FOR VETERINARIAN USE ONLY
Clients interested in a vet-to-vet behavior medication consultation between their primary veterinarian and Dr. Gilbert-Gregory should contact their primary veterinarian directly to discuss whether this option is a good fit for your pet. Please note, you can start, then return to finish this form later. Please copy the link to return to the form if you choose to do so in case.
I am a vet seeking a consult for:
My client that has been working with Gigi's Behavior Services
My client that has NOT been working with Gigi's Behavior Services
My own pet
A renewal over 6 months after the initial consult
By checking here:
*
I acknowledge that I am a licensed veterinarian with an active VCPR and legal prescribing privileges for the patient described in this request.
How did you hear about us?
Veterinarian's Name
*
First Name
Last Name
Clinic Name
*
Clinic location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Veterinarian's email
*
example@example.com
Veterinarian's phone (clinic)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Veterinarian's phone (personal)
optional
Format: (000) 000-0000.
Preferred contact method (check all that apply)
*
Email
Clinic Phone
Personal Phone (call)
Personal Phone (text)
Which weekday & time work best for your consult?
*
Monday: 5-7PM
Wednesday: 8-9AM
Thursday: 5-7PM
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Client's name
*
First Name
Last Name
Client's email
*
Client's location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet's Name
*
Pet's Date of Birth
*
Approximate if unknown
Pet's Breed
*
State small/med/large mix if unknown
Sex
*
Male Intact
Male Neutered
Female Intact
Female Spayed
Pet's Weight (kg) and date of last weight
*
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Date of last physical exam
*
We recommend that the pet has been examined within the last 3 months and/or history review prior to the consult
Primary reason for considering behavior medication
*
0/200
Current medication and response
*
0/200
Discontinued medication and response
*
0/200
This pet has a history of (check all that apply)
*
Seizures
Heart disease
Chronic/intermittent loose stools
Constipation
Dry eye or glaucoma
None of the above
This pet has a history of growling, snarling, snapping, nipping, biting (may or may not have caused injury)
*
Yes
No
Pertinent medical history
*
0/200
Rate this pet's appetite 0 (won't eat anything) to 10 (eats everything in sight)
*
Rate this pet's activity level when not triggered 0 (couch potato, not interested in activities) to 10 (struggles to settle or relax all of the time)
*
Client is currently (within 3 months) working with a trainer, behavior consultant or behaviorist?
*
No - not interested
No - have in the past
No - interested in working with one
Yes - Gigi's Behavior Services
Yes - Another trainer/behavior consultant/behaviorist
Other
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