Veterinary Behaviour Referral Form

Practice Information

Referring/contact veterinary surgeon

Practice name

Practice contact number

Practice email

Practice postcode

Client Information

Client name/s

Client address

Country/Region

Address

City

Zip / Postal code

Client contact number

Client email

Patient(s)

Patient's name

Date of birth / approx. age

Species/breed

Sex and neuter status

Behaviour Details

Brief description of behaviour

When was it first noticed (if known)

Has euthanasia been considered?

Yes

Medical History

Date of last health check

Weight

Were you able to clinically examine the patient?

Yes

Please indicate if there are any current medical problems

Details of any ongoing medical conditions or treatments

Full medical history and laboratory test results

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Declarations

The owner has consented to the disclosure of clinical information regarding the above-mentioned pet for the purposes of referral.

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.

All information provided above is correct to the best of my knowledge. I hereby certify my approval for the client described overleaf to be referred for management of the current behaviour problem to Forrest Animal Behaviour.

Signed

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RCVS number