Equine Dermatology Veterinary Referral
Referral Policy
At PetDerm, we are committed to providing the highest standard of dermatological care for referred patients. To ensure a seamless referral process and the best possible outcomes for equine and their owners, we ask that all referring veterinarians to submit referrals via this form. Please complete the patient history, including previous dermatological treatments and response to therapy. Include any relevant diagnostic test results, medical history from all veterinarians visited, and any pertinent images. The form allows you to conveniently upload image files and medical records. Upon form submission, you will receive a confirmation of the accepted referral. After the patient's consultation, PetDerm will provide referring veterinarians with a summary of findings, diagnosis and treatment recommendations. **We ask that you refrain from performing advanced diagnostics, such as biopsies or specialized testing, until the PetDerm Dermatology team has assessed the patient, as this allows us to determine the most appropriate diagnostic and treatment approach. We appreciate your collaboration in helping us provide the best dermatological care for your patients.
Owner Information
Name
*
First Name
Last Name
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Equine Information
Equine Name
*
Breed
Please Select
Warmblood
Quarter Horse
Irish Sport Horse
Dutch Warmblood
Draft Hose
Quarab
Arabian
Thoroughbred
Canadian Warmblood
Paint
Morgan
Other
Sex
*
Please Select
Stallion
Gelding
Mare
Birthdate
-
Month
-
Day
Year
Date
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Referral Urgency
What is the urgency of this referral?
*
Urgent (photos are required)
Priority (photos are required)
Next available appointment
Please provide details as to why this patient requires to be seen urgently.
*
Please provide details as to why this patient requires a priority appointment.
*
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Family Vet Information
Referring Clinic
*
Referring Veterinarian
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Clinic Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Has this patient been to any other veterinary clinics?
Important Information
At PetDerm, we practice Fear Free techniques to provide the best care with minimal stress for our patients. In keeping with our approach, if you answer YES to the question below, a PetDerm team member will reach out to you prior to your consultation. Thank you.
Please select an option that best suites the patient's requirements in a veterinary setting
Please select an option that best suites the patient's requirements in a veterinary setting
Patient is anxious/nervous and would benefit from oral sedation.
Patient is highly fractious and would benefit from IV sedation.
Other
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Veterinary History
Reason for Referral
*
How long has the problem been going on?
*
Relevant dermatological history
*
Any other health issues not dermatology related?
*
Relevant diet history/information
*
Please provide deworming dates and medication name/dose.
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Vaccination History
Please select applicable vaccines and date administered.
6 Way Vaccination - WEE, EEE, Tetanus, Influenza, Equine Herpres Virus, West Nile
Yes
Date Administered
-
Month
-
Day
Year
Date
5 Way Vaccination - WEE, EEE, Tetanus, Influenza, Equine Herpres Virus
Yes
Date Administered
-
Month
-
Day
Year
Date
4 Way Vaccination - WEE, EEE, Tetanus, Influenza
Yes
Date Administered
-
Month
-
Day
Year
Date
3 Way Vaccination - WEE, EEE, Tetanus
Yes
Date Administered
-
Month
-
Day
Year
Date
3 Way Vaccination - WEE, EEE, Tetanus + West Nile
Yes
Date Administered
-
Month
-
Day
Year
Date
Calvenza - Influenza, Equine Herpes Virus
Yes
Date Administered
-
Month
-
Day
Year
Date
Pinnacle IN Strangles
Yes
Date Administered
-
Month
-
Day
Year
Date
West Nile Virus
Yes
Date Administered
-
Month
-
Day
Year
Date
Prodigy Rhinopneumonitis (pregnant mares)
Yes
Date Administered
-
Month
-
Day
Year
Date
Rabies
Yes
Date Administered
-
Month
-
Day
Year
Date
Other:
Date Administered
-
Month
-
Day
Year
Date
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Additional Information
Please list all diagnostic tests performed
Additional comments and concerns
Relevant Images of Skin or Medical History
Browse Files
Drag and drop files here
Choose a file
If the file size is larger than 5mb, please email directly to admin@petderm.ca and reference the pet's first and last name in the subject.
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