Referral Form

A referral service in behavioural medicine

November 6, 2020 / bydanielhorton / 0

Referral Form for Animal Behaviour Case

Behaviour problems may arise both directly and indirectly as a result of concurrent or previous medical problems. Veterinary involvement is therefore essential in eliminating organic causes of the problem and prioritising the diagnostic and treatment strategy to be used in any given case. In order to safeguard the welfare of your patient and indicate your approval of referral, please complete the following form. Please note that until a case is released to another veterinary surgeon then you, as the client's normal veterinary surgeon, remain responsible for the treatment, advice and any prescriptions given.

I hereby acknowledge my approval for the following client to be referred for management of the current behaviour problem to Behaviour Referrals Veterinary Practice.*
- Yes
Practice Information
Referring/Contact Veterinary Surgeon*
Practice Name*
Practice Phone Number*
Practice Fax Number
Practice Email*
Practice Postcode*
Client Information
Your Address*
Address Line 1 Address Line 2 City County Postal Code Country
Practice Address*
Address Line 1 Address Line 2 City County Postal Code Country
Client Name*
First Last
Client Phone Number*
Client Email Address*
Patient Name*
Species/Breed*
Date of Birth*
Sex (incl. neuter status)*
Insurance Company
Behaviour Details
Brief details of behaviour problem*
Date first noticed*
Has euthanasia been considered?*
- Yes
- No
- Other
If 'other' please give more information
Medical History
Date of last health check*
Weight (kg)*
Please attach full medical history.*
Max. file size: 512 MB.
Please indicate if there are current or previous health problems concerning the following and attach appropriate details
- Allergic reactions
- Cardiovascular system
- Endocrinological system
- Muscular skeletal system
- Nervous system
- Orolaryngeal region
- Respiratory system
- Sensory systems
- Skin and adnexae
- Urogenital system
Please provide details of any blood screens performed including specific organ function tests and assays
Date and purpose of any general anaesthetics
Details of any ongoing medical conditions or treatments
The owner has consented to the disclosure of clinical information regarding to the above mentioned pet for the purposes of referral*
- Yes
In line with the latest guidelines issued from RCVS with respect to tele-prescribing, 'I' (as the primary vet to the patient I am referring), take responsibility either ourselves as the veterinary practice or via our out of hours primary care provider, that 24 hour care will be available for a physical exam should the patient need it*
- Yes
Date*
DD slash MM slash YYYY

Referral Form

Referral Form for Animal Behaviour Case

Practice Information

Client Information

Behaviour Details

Medical History

danielhorton