Referral Form | V.A.D.E.R. Clinic

Client Information

Surname *

First Name *

Main Phone Number *

Secondary Phone Number

Address Line 1 *

Address Line 2

City/Town *

Postal Code *

Province *

e-mail *

Pet's Name *

Pet's Age *

Pet's Weight (kg) *

Breed *

Sex *

Colour *

Veterinary Clinic Information

Doctor *

Clinic *

Phone *

Fax *

Address Line 1 *

Address Line 2

City/Town *

Province *

Postal Code*

E-Mail *

Is this client veterinary staff? *

YesNo

are you the primary care Veterinarian? *

YesNo

Who is the Primary Care Veterinarian? *

Important Information

Do not bathe your pet for at least 5 days prior to your appointment and do not feed you pet for at least 12 hours to your appointment (UNLESS OTHERWISE SPECIFIED BY YOUR VETERINARIAN).
Please note that pets referred to our facility can only be treated for skin related disorders. All other unrelated treatment or procedures willl be conducted by your family veterinarian.

Relevant Medical History

Describe any relevant non-dermatological disease and/or any antibiotic or anesthetic sensitivities

Dermatology History

describe the course of the disease (Age of onset, Seasonality, other) and lesions noted *

Oral Sedation

Does this pet require oral sedation for the consultation? *

If yes, please specify the medication(s) strength and dosage that you prescribed for their Dermatology consultation:

YesNo

Oral Sedation Medication

Medication name *

Concentration *

Concentration Unit *

Dose *

Dose Units *



Add Sedation Medication

Therapeutic History

Please include previous topical treatments including shampoo, sprays, mousse and ear treatments.

Date

Medication name

Dose

Dose Units

Duration

Medication Result



Add Medication

Is the pet on heartworm or flea medication? *

YesNo

Which Medication? *

Has this patient required muzzling during an exam? *

YesNo

Dietary History

Please include previous veterinary diets.

Date

Diet

Duration

Diet Response



Add Diet

Diagnostic Tests

Please upload recent (within the last 6 months) labwork results for this pet, and pertinent dermatologic history.

Upload File

Max file size 10MB.

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List any diagnostic tests performed

list any concerns or comments

Important Information

At VADER Clinic, we practice Fear Free Techniques to provide the best care with minimal stress for our patients. In keeping with our Fear Free approach, we ask that you prescribe Gabapentin for all feline patients referred to us for a consultation. Please have clients administer the Gabapentin at least 90 minutes prior to their appointment time. Thank you.

Dermatology Referral Form

Client Information

Veterinary Clinic Information

Important Information

Relevant Medical History

Dermatology History

Oral Sedation

Oral Sedation Medication

Therapeutic History

Dietary History

Diagnostic Tests

Important Information