REFERRING VET INFORMATION

Veterinarian

Practice

Email Address

Phone

CLIENT & PATIENT INFORMATION

Client(s) Name(s)

Client Email Address

Last body weight (kg):

Patient Name

Client Phone

Patient Age/ DOB:

Species

Breed

Preferred method for receiving patient reports: Preferred method for receiving patient reports: Email Fax

Sex SexMF

Diet Trial History

Main reason(s) for referral: Main reason(s) for referral: Ear disease Pruritus/itching/allergies Chronic skin infections Alopecia (Hair-loss) Pododermatitis Neoplastic and Non-Neoplastic Tumour(s) Nail Disorder Pigmentary abnormality Auto-immune and Immune-mediated Dermatoses Bee/Wasp Anaphylaxis Other

Clinical Signs and History: (an abbreviated version is fine providing the patient record is emailed through)

ADDITIONAL INFORMATION: Pet’s temperament, comments or special requests

NON-DERMATOLOGICAL DISEASES: (e.g. osteoarthritis in hips or IMHA)

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