Veterinary Behaviour Referral Form

Veterinary Behaviour Referral Form
PLEASE ENSURE THAT THIS ENTIRE FORM IS COMPLETED.

If you are short on time another member of staff may complete it for you to then check over and sign. You can also SAVE this form at the bottom and return later to finish completing it.

As a Clinical Animal Behaviourist and full APBC member obtaining this referral form is required. Veterinary referral is important to rule out any underlying medical conditions as problem behaviour can occur from arising or previous medical conditions. Veterinary involvement will eliminate this aspect of the problem, so treatment can be focused on. It will also provide a point of contact should we need to discuss anything with you.

PLEASE NOTE:

1) The owner will also be automatically emailed with a copy of this submission, please ensure you enter their email address correctly.

2) This form is for VETERINARY SURGEON referral, forms completed by the owner will not be accepted

PRINTED COPIES WILL NOT BE ACCEPTED

If you have any issues completing this form online please use the contact form HERE to let us know detailing the issue so we can look into it OR so we can help you with a work around if your time is short.
Owner & Animal Details
Owner Name*

PrefixFirst NameLast Name
Owner Email (please ensure this is correct as the owner will receive a copy)*
example@example.com
If an incorrect email address is entered in the box above the owner will not receive vital information and the process cannot be completed accurately.

In this instance it is vital the owner is instructed that they must reach out if they are to book in for any help.
*

I understand the above information and will ensure I provide accurate information
Phone Number

Area CodePhone Number
Mobile Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Animal Name*

First NameLast Name
Animal Details*

SpeciesBreed
Animal Details*

AgeF/ FN / M / MN - please write one
GDPR: I confirm the client has provided full consent for their details to be shared with Katey Aldred*

Yes
To proceed: the owner must pre-book an appointment, and complete a behaviour questionnaire, plus agree to the full terms and conditions of service. Please visit www.kateyaldred.co.uk for more information and ensure your client understands this.*

I understand
Veterinary Surgeon Section

In order to certify your approval for referral and safeguard the well-being of both your clients and their pet, please complete the following form and return it with the medical history. If you wish to post this please contact Katey for a postal address.
Referring Practice Name & Address*

Practice Name

Address

TownCounty

Post Code
Referring/Contact Veterinary Surgeon*

PrefixFirst NameLast NameSuffix
Referring Veterinary Surgeon Email*
example@example.com
Practice Email*
example@example.com
Phone Number*

Area CodePhone Number
Brief Details of the behaviour issue including a date first reported/noticed *
Date this issue was first noticed or duration it has been present?
If aggression is present is there any concern for safety?*

YesNoNo aggression present
Has the owner consider euthanasia or rehoming?*

Yes: EuthanasiaNo : EuthansiaYes: RehomingNo: Rehoming
Date of last health check:*
Weight*
KG
Please indicate current or previous health problems concerning the following (ensure you send the relevant history).*

Allergic ReactionsGastro-intestinal systemSkin and adnexaCardiovascular systemRespiratory systemUrogentital systemEndocrinological systemSensory systemNervous systemMusculo-skeletal SystemNo issues with any system currently or previously
Have you conducted any of the following:*

Orthopedic examinationPain screeningCheck earsNone of the aboveOther
Please provide details including dates of: Specific blood tests including specific organ tests and assays; orthopaedic examination including any slight reactions or muscle issues.*
Date and purpose of any general anaesthetics *
Details of any ongoing medical conditions or treatments*
Current medication (pre-scribed or otherwise)*
Please upload any relevant history here (if you cannot upload files due to your system please email them when you receive your conformation of submission email)*

Browse Files

Cancelof
Please upload any other supporting documents you would like to submit (test results for example)

Browse Files

Cancelof
Summary of medical history attached?

YesI will email this in reply to submission confirmation
Can Katey contact you to discuss any concerns?*

YesNo
Please note that until a case is released to another Veterinary Surgeon, then you, as the client’s normal Veterinary Surgeon remain responsible for the treatment, advice, and any prescriptions given. I hereby acknowledge my approval for the client described above to be referred to Katey Aldred & Pooch Paws for management of the current behaviour problem
Veterinary Surgeon Signature (forms will not be accepted without this)
Should be Empty:

Veterinary Behaviour Referral Form

Owner & Animal Details

Veterinary Surgeon Section