Fairmont Dermatology rDVM Referral Form
Veterinary dermatology referral form for Fairmont Animal Hospital (Dr. Zhang). Please complete the patient, owner, referral, medical history, diagnostics, and records checklist details as shown in the reference form.
Patient Information
Patient Name
*
Species
*
Please Select
Canine
Feline
Breed
Age
Sex
*
Please Select
Male
Female
Neutered (Male)
Spayed (Female)
Owner and Referring Clinic Information
Owner Name
*
Owner Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Owner Email
*
example@example.com
rDVM / Clinic
*
Referring DVM
*
Referring DVM email
*
example@example.com
Referral Details
Referral Type
*
Please Select
Initial dermatology consult
Recheck/follow-up
Second opinion
Main concerns / reason for referral
*
Specific questions for Dr. Zhang
Medical History and Treatments
Patient temperament
Known allergies / previous reactions
Other medical conditions
Current medications
Previous medications / treatments
Previous diet trials
Diagnostics and Endocrine Testing
Previous diagnostic results
Skin scrapings
Cytology
Fungal culture
Bacterial culture/sensitivity
Allergy testing
Endocrine testing
Other
Has the patient been tested for endocrine disease?
Yes
No
Endocrine disease test results
rDVM acknowledgement if endocrine testing not performed
I confirm endocrine testing was not performed and understand this information may be requested
Other
Is the patient considered an anaesthetic risk?
Yes
No
Unsure
Anaesthetic workup components completed
Physical exam
CBC
Biochemistry profile
Urinalysis
Thoracic radiographs
ECG
Blood pressure
Other
Other relevant testing completed
Records Checklist and Submission
Complete medical history attached
*
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Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referral submitted by
*
Submit
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