Last Name
*
First Name
*
Owner's Main Phone Number
*
(###)
###
####
Owner's Secondary Phone Number
(###)
###
####
Address Line 1
*
Address Line 2
City/Town
*
Province
*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
*
EMAIL
*
Is The Client A Staff Member At Your Clinic?
*
Horse's Name
*
Horses's Age or Date of Birth
*
Horse's Weight (KG)
*
Breed
*
Sex
*
Stallion
Gelding
Mare
Colour
*
Doctor
*
Clinic
*
Clinic Phone Number
*
(###)
###
####
Fax
Address Line 1
*
Address Line 2
City/Town
*
Province
*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
*
Clinic EMAIL
*
Are You The Primary Care Veterinarian?
*
Primary Care Clinic (If not the referring clinic)
What Skin Issues Are You Referring The Patient For?
*
i.e. Allergies, Itch, Skin Infections, Hives, Head Shaking, Pemphigus Foliaceous, ETC
Oral Or Injectable Steroids
*
If Yes, Please Explain
Apoquel
*
If Yes, Please Explain
Antihistamines
*
If Yes, Please Explain
Pentoxifylline
*
If Yes, Please Explain
Systemic Antibiotics In The Last 6 Months
*
If Yes, Please Explain
Other Immunosuppressive medications
*
i.e. AZATHIOPRINE, ETC
If Yes, Please Explain
Omega-3 And/Or Omega-6
*
If Yes, Please Explain
Topical Therapies Including Shampoo Or Ointments, ETC
*
If Yes, Please Explain
Does The Patient Have Any Other Medical Issues? (Cushings, Equine Metabolic Syndrome, ETC.)
Please indicate if these conditions are well managed at this time.
Is The Patient On Any Other Medications/Supplements Unrelated To Their Dermatologic Issues?
Any Other Information That You Feel Is Relevant To This Case?
Do You Have Files To Upload?
*
