Veterinary Referral Form

Veterinary Referral Form
Clinic Name
Veterinarian Name
Clinic Phone Number
Clinic Email
Preferred Method of Communication
Client Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred method of contact
Patient Information
Cat's Name
Age
Sex
Breed
Medical History & Status
Current or recent medical conditions
Current medication/Supplements
If So, please include name, dose, frequency
Any recent surgeries or procedures?
Date of last veterinary exam

MonthDayYear
Date
Date of Rabies Vaccination

MonthDayYear
Date
1 year or 3 year vaccine?
Is the cat currently under veterinary care for this issue?
Diagnostics & Rule-Outs
Have medical causes been ruled out for the behavior concern?
Diagnostics performed

Other
Any findings relevant to behavior
Behavior Concern
Primary Concern

Other
Duration of issue
Frequency of behavior
Brief description of behavior
Pain & Behavior Considerations
Is pain suspected as a contributing factor
Has pain management been trialed
Additional notes on behavior/medical interaction
Referral Goals
What are your goals for this referral?
Behavior modification, environmental changes, client education
Additional comments or recommendations
Consent
I confirm that the client is aware of and consents to this referral
Upload medical records, lab results, or relevant documents

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Cat Intel provides feline behavior consulting and does not diagnose or treat medical conditions. All recommendations are based on the information provided and are intended to complement veterinary care. Clients should maintain ongoing communication with their veterinarian regarding medical concerns.
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Veterinary Referral Form

Client Information

Patient Information

Medical History & Status

Diagnostics & Rule-Outs

Behavior Concern

Pain & Behavior Considerations

Referral Goals

Consent