Veterinary Referral Form
Referring Veterinary Surgeon
Veterinary Practice
Practice Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Practice Email
example@example.com
Clients Name
*
Client Email
*
example@example.com
Client Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Patients Name
*
Species
*
Please Select
Dog
Cat
Bird
Rabbit
Other
Breed
Age DOB
Sec and Neutered Statis
Male Entire
Male Neutered
Female Entire
Female Spayed
Reason for Referral
*
Lead Reactivity, Resource Guarding, Separation Anxiety, Sudden Changes of Behaviour
Relevant Medical History or Additional Notes
Has patient been physically examined for underlying pain or pathology relevant to these behaviour changes.
Yes, examined within the last 14 days
Yes, examined within the last 30 days
No, pending examination
Are you able to clinically examine the patient:
Is there any current evidence or high suspicion of chronic orthopedic, musculoskeletal, gastrointestinal or neurological pain?
No known pain
Orthopedic / Musculoskeletal pain suspected or diagnosed
Neurological discomfort or sensory sensitivities
Gastrointestinal / Digestive distress suspected (e.g, chronic soft stools, acid reflux, selective appetite, unexplained food changes)
Dental, periodontal. or orofacial pain suspected (e.g head-shyness, chewing on one side, sudden handling, sensitivity around the muzzle)
Co-morbidities under active investigation
Please list any relevant history, dietary changes, NSAIDs, pain management trails or behavioural medications.
Secure File Upload: Clinical Records & Lab Results (Optional)
Upload a File
Drag and drop files here
Choose a file
If you have an export of the patients recent clinical history or blood panel notes, you can drag and drop it here, otherwise feel free to leave this free.
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of
Consent
I hereby confirm my consent for the client to be referred for the current behaviour problem to Teaching Tails Dog Training & Behaviour. I understand that a copy of the full report, detailing the assessment and treatment plan, will be sent to me if requested.
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