A dog at a lake between mountains. Traveling with the pet. Australian Shepherd. Nature. Au

Veterinary Referral Form

As per the APBC code of conduct, I see all behaviour cases on Veterinary referral. Therefore, I ask for the referral form below to be completed for behaviour referrals and for a copy of the patient's clinical history (including any test results) to be uploaded.

If you prefer, a copy of the form can be downloaded here and emailed to karen@petbehaviourconsulting.co.uk, along with the clinical history.

After consultations, I provide referring Veterinary Surgeons with a summary report to keep you and your client's records up to date.

Practice Details

Veterinary Practice name

Address, including postcode

Contact number

Client Details

Client's name

Client's address

Contact number

Patient Details

Dog's name

Dog's breed, mix or cross

Male/Female

Is the patient neutered or entire?

Date of most recent health check?

Brief desciption of behaviour problem

Can you clinically examine the patient?

Did the patient require additional forms of restraint (e.g. owner or nurse holding, use of a muzzle, etc.)?

If referring directly, how would the owner prefer to be contacted?

Phone

Self referral - I have been requested to complete the referral

Consent

I acknowledge my consent for the above client and patient to be referred to Karen Bachell with regard to training/behavioural issues

If referring directly, the client has confirmed they would like Karen to get in contact, via their preferred method, to arrange appointment bookings

Your Signature

Print name

Date signed

Clinical history

Please upload the patient's clinical history, including any test results.

Upload History

Upload Additional File