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.*YesPractice InformationReferring/Contact Veterinary Surgeon*Practice Name*Practice Phone Number*Practice Fax NumberPractice Email*Client InformationAddress* Street Address Address Line 2 City County Postal Code Practice Address* Street Address Address Line 2 City County Postal Code Client Name* First Last Client Phone Number*Client Email Address* Patient Name*Species/Breed*Date of Birth*Sex (incl. neuter status)*Insurance CompanyBehaviour DetailsBrief details of behaviour problem*Date first noticed*Has euthanasia been considered?*YesNoOtherIf 'other' please give more informationMedical HistoryDate of last health check*Weight (kg)*Please attach full medical history.*Please indicate if there are current or previous health problems concerning the following and attach appropriate detailsAllergic reactionsCardiovascular systemEndocrinological systemMuscular skeletal systemNervous systemOrolaryngeal regionRespiratory systemSensory systemsSkin and adnexaeUrogenital systemPlease provide details of any blood screens performed including specific organ function tests and assaysDate and purpose of any general anaestheticsDetails of any ongoing medical conditions or treatmentsThe owner has consented to the disclosure of clinical information regarding to the above mentioned pet for the purposes of referral*YesIn 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*YesCAPTCHA
