Referral Form

Client name

Phone

Patient name

Patient age

Presenting problems

Training method used (if known)

Address

Patient breed

Date first started

Current behavior medications

Other current medications

Are there any medication reactions we need to know about this patient?

Other health diagnoses

Please describe this patient’s behavior in your clinic...

If sedated, what was the response to sedatives?

PLEASE NOTE THAT ANY ONGOING HEALTH CONDITIONS WILL NOT BE ADDRESSED AND REFERRED BACK FOR ONGOING CARE SHOULD THEY ARISE IN ANY WAY. IF THERE IS A HEALTH CONDITION THAT NEEDS TO BE FURTHER INVESTIGATED THAT MAY BE CONTRIBUTING TO THE BEHAVIOUR CONCERN, THE PATIENT WILL BE SENT BACK TO YOU FOR DIAGANOSTIC WORKUP.

A behavior report will be emailed to you approximately 7 days after the consultation. An email indicating an appointment booking has been made will also be sent. Please note that if you choose to perform blood testing for behavior medication use, please email a copy to us at your earliest convenience.

If so, please provide method and ideal times...

Thank you for your time and referral. I appreciate your effort in assisting this process and patient.

Kind regards,

Dr. Eva Dudzic

Please share any pertinent information regarding this pet and/or client...