REFERRING VET INFORMATION

Veterinarian

Practice

Email Address

Phone

CLIENT & PATIENT INFORMATION

Client(s) Name(s)

Client Email Address

Client Phone

Patient Name

Patient Age/ DOB:

Breed

Last body weight (kg):

Sex SexMF

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

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

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

Diet History

NON-DERMATOLOGICAL DISEASES: (e.g. laminitis)

ADDITIONAL INFORMATION: Comments or special requests