Small Animal Referral Form

OWNER'S MAIN PHONE NUMBER *

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OWNER'S SECONDARY 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

CYTOPOINT (Dogs Only) *

YES

NO

ZENRELIA (Dogs Only) *

YES

NO

ATOPICA *

YES

NO

OTHER IMMUNOSUPPRESSIVE MEDICATIONS *

i.e. AZATHIOPRINE, CHLORAMBUCIL, MYCOPHENOLATE, ETC)

YES

NO

SYSTEMIC ANTIBIOTICS IN THE LAST 6 MONTHS *

YES

NO

SYSTEMIC ANTIFUNGALS IN THE LAST 6 MONTHS *

YES

NO

OMEGA-3 AND/OR OMEGA-6 FATTY ACIDS *

YES

NO

EAR MEDICATIONS IN THE LAST 6 MONTHS *

YES

NO

TOPICAL THERAPIES INCLUDING ANTISEPTIC SHAMPOOS, MOUSSES, CREAMS *

YES

NO

HAS THE PATIENT RECEIVED FLEA, TICK OR HEARTWORM PREVENTION *

YES

NO

DOES THIS PATIENT REQUIRE A MUZZLE OR ORAL SEDATION TO BE EXAMINED? *

YES

NO