Client Registration Form

Veterinary Referral Form
Referral Information
Referring Veterinarian:
Referring Hospital:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
If we need to contact you or your clinic, which email should we use?
example@example.com
Client Information
Name of the primary caregiver:
Client's Email:
example@example.com
Client's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Is there anything else we should know about this client?
Patient Information
Patient's Name:
Species
Species:
Patient's Breed:
Patient's Age or DOB:
Patient's Sex
Weight:
Specify kgs, or lbs
Date of last Rabies vaccination
All patients must be Rabies vaccinated in accordance with Georgia state law
Vaccination type
What is your goal in referring this patient?
Patient Clinical History and Status
Brief History:
Prognosis:
Current/Prescribed medications and treatments
Is this pet on a prescription diet?
Prescribed diet, amount, and frequency
Are there any treats/food contraindicated for this patient?
Contraindicated food items:
Approved nursing care tasks:

Other
Please select recommended/approved ear cleaner
Please list instructions in medications and treatments
Patient Comfort and Handling
Does this patient have a history of fear, anxiety, or stress?
Please list the signs patient exhibits during visits:
Does this patient have a history of aggression or biting?
Please explain:
Does this patient typically require or benefit from pre-visit pharmaceuticals to be seen in-clinic?
Likes (prevents/alleviates FAS):
Triggers (increases FAS):
To minimize stress and pain for patients during home treatments, do you authorize the application of topical lidocaine/prilocaine 2.5%/2.5% cream prior to needled procedures?
Preferred Distraction Techniques

Other
Preferred food/treats:
eg. chicken, cheese; crunchy, soft, lickable
Behavior Management Products

Other
Is there anything else we should know about this patient?
Please upload any pertinent medical history you would like for me to have

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Veterinary Authorization & Signature
By signing below, I certify that a valid Veterinarian-Client-Patient Relationship (VCPR) exists for the patient listed above. I authorize Nicole De Lisle, LVT, to perform treatments in the patient's home within her scope of practice according to the Georgia Veterinary Practice Act.
Additional Details
Should be Empty:

Veterinary Referral Form

Referral Information

Client Information

Patient Information

Patient Clinical History and Status

Patient Comfort and Handling

Veterinary Authorization & Signature