Equine Referral Form

OWNER'S MAIN PHONE NUMBER *

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OWNER'S SECONDARY PHONE NUMBER

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IS THE CLIENT A STAFF MEMBER AT YOUR CLINIC? *

YES

NO

CLINIC PHONE NUMBER *

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ARE YOU THE PRIMARY CARE VETERINARIAN? *

YES

NO

ORAL OR INJECTABLE STEROIDS *

YES

NO

APOQUEL *

YES

NO

ANTIHISTAMINES *

YES

NO

PENTOXIFYLLINE *

YES

NO

SYSTEMIC ANTIBIOTICS IN THE LAST 6 MONTHS *

YES

NO

OTHER IMMUNOSUPPRESSIVE MEDICATIONS *

i.e. AZATHIOPRINE, ETC

YES

NO

OMEGA-3 AND/OR OMEGA-6 *

YES

NO

TOPICAL THERAPIES INCLUDING SHAMPOO OR OINTMENTS, ETC *

YES

NO