Dermatology Referral Form

Non-Veterinarians Including Pet Owners:

This form is for referrals from veterinarians ONLY. If you are a pet owner seeking a referral, please talk to your family veterinarian. We cannot respond to referral requests from non-veterinarians. We thank you for your understanding.

Owner Information

First Name*

Last Name*

Home Phone*

Email*

Business Phone*

Address*

Province*

City/Town*

Postal Code*

Pet Information

Pet's Name*

Age*

Pet's Weight*

Breed*

Sex*

Colour*

VETERINARY CLINIC INFORMATION

Doctor*

Postal Code*

Clinic*

Phone*

Address*

Fax*

City/Town*

Email*

Please note

  1. Do not bathe your pet for at least 5 days prior to your appointment and do not feed you pet for at least 12 hours to your appointment (UNLESS OTHERWISE SPECIFIED BY YOUR VETERINARIAN).
  2. Please note that pets referred to our facility can only be treated for skin related disorders. All other unrelated treatment or procedures willl be conducted by your family veterinarian.

RELEVANT MEDICAL HISTORY

Does the pet have any relevant non-dermatological disease? Are there any antibiotic or anesthetic sensitivities? If so, please describe:

DERMATOLOGIC HISTORY

Please briefly describe the course of the disease (age of onset, seasonality, other) and lesions noted:

THERAPEUTIC HISTORY

Please list medications used, including does, dates of treatment and any response.

Date Started

Date Finished

Medication

Dose/Duration

Result

Is the pet on heartworm or flea prevention?

If yes, which?

DIAGNOSTIC TESTS

Please send along copies of any diagnostic tests. Otherwise, please list any diagnostic tests performed, with date run and full results:

Please list any concerns or comments:

Verification Code (required)

Please answer math questions with single digits. Do not spell the number.