BEHAVIOURAL CONSULTATION REFERRAL FORM

BEHAVIOURAL CONSULTATION REFERRAL FORM

This form must be filled out by the referring vet. If you are a dog guardian interested in a behavioural consultation, please contact your vet practice asking for a referral by completing this form
Undesirable behaviours can arise both directly and indirectly as a result of previous or concurrent medical issues. Veterinary involvement is therefore essential in eliminating medical causes of the problem, prioritising the diagnostic treatment strategy to be used in any given case.

If referring more than one pet from one household, please use separate forms for each referred patient.
Referring Vet Details

Please input the information for the specific veterinarian at the practice that agrees to be the point of contact for ongoing communication, treatment and any prescriptions advised.
Referring Veterinary Surgeon's Title
Referring Veterinary Surgeon's Name

First NameLast Name
Veterinary Practice Name
Practice Phone Number

Area CodePhone Number
Practice Email
example@example.com
Practice Address

Street Address

Street Address Line 2

CityCounty

Post Code
Client Details
Client's Title
Client's Full Name

First NameLast Name
Client's Phone Number
Please enter a valid phone number.Format: (+44)0000 000000.
Client's Email Address
example@example.com
Client Address

Street Address

Street Address Line 2

CityCounty

Post Code
Please note that clients based outside of Hertfordshire, and/or with dogs aggressive behaviour(s) towards visitors, the initial consult will be online, for the safety and welfare of staff, the client and pet. Further session location will be discussed during the initial consultation.
Patient Details
Patient Name
Breed(s)
Date of Birth

DayMonthYear
Patient Sex
What age was the patient at the time of neutering?
If applicable, who is the pet insured with?
Medical and Behavioural Details
Is the patient on any medications?
Please detail what medications they are receiving including doses, frequency of administration, the duration the patient has been on them and what improvement, if any, has been seen
Has the patient had a health check in the last 4 weeks?
All patients should have a health check 1-4 weeks prior to behavioural referral, to cancel out any pain or illness, the cause of up to 80% of unwanted behaviours. Therefore, I cannot accept referral without a recent health check.
Where there any indicators of pain or illness in this recent health check?
Please detail what signs of pain and/or illness were present:
Please attach a complete medical history here, including any blood tests

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Please provide brief details of behavioural complaint(s) deemed by a) the client and b) yourself
Date first noticed

DayMonthYear
Has euthanasia been considered?
Please provide specific information regarding any aggression, including any risks to safety
If applicable, please attach any photos or videos

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Terms & Conditions
I confirm the client has consented to the disclosure of clinical information for the purpose of referral
In line with RCVS and CCAB guidelines, I, as the client's usual veterinary surgeon, remain responsible for the treatment, advice, and any prescriptions given, whether through our primary practice or your out-of-hours provider.
I understand a copy of the full report will be sent to me by email within approximately one week of the consultation
I acknowledge my approval for the above client to be referred to Bronwyn Bailey, BBBehaviourist.
Date

DayMonthYear
Should be Empty:

BEHAVIOURAL CONSULTATION REFERRAL FORM

Referring Vet Details

Client Details

Patient Details

Medical and Behavioural Details

Terms & Conditions