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Behavioral Medicine Service Referring Veterinarian Form

Behavioral Medicine Service Referring Veterinarian Form

NOTE: This form is intended to be filled out only by a referring DVM or hospital representative. Owners should seek referrals from their veterinarian.

Veterinarian Information

Veterinarian Name(Required)

Veterinarian Clinic(Required)

Clinic Phone Number(Required)

Clinic Email(Required)

Referral Agreement(Required)

By submitting this referral to the University of Georgia’s Behavioral Medicine Service, it signifies the referring veterinarian listed above has an established veterinarian-client-patient relationship (VCPR) for the patient listed below.

Client Information

Owner's Name(Required)

Owner's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Owner's Primary Phone Number(Required)

Owner's Secondary Phone Number

Owner's Email(Required)

Patient Information

Patient's Name(Required)

Patient’s Species(Required)

Patient’s Breed(Required)

Patient’s Color(Required)

Patient’s Sex(Required)

Patient’s Age or Date of Birth(Required)

Patient’s Weight(Required)

Date of Patient’s Last Rabies Vaccination(Required)

Vaccination Type(Required)

1 Year

3 Year

Important: Rabies vaccinations are required in order for us to see the patient. A rabies titer is not acceptable as proof of a current vaccine.

Patient Medical History

Pertinent Medical History and Exam Findings(Required)

List of Patient’s Current Medications

Name of Medication

Strength of Medication

Frequency Given

Have any Previous Psychoactive Medications Been Tried?(Required)

Yes

No

If Yes, please list them below(Required)

Name of Medication

Strength of Medication

Frequency Given

Diagnostics Performed

Important: We do require that full comprehensive labwork (Chemistry, CBC, Urinalysis, & T4) to be performed within the past 6 months.

Diagnostics

Full Panel Chemistry

CBC

Urinalysis

T4 or Thyroid Profile

Other

Date Last Performed (Full Panel Chemistry)

Results (Full Panel Chemistry)

Normal Ranges

Abnormal

If abnormal, please list results

Date Last Performed (CBC)

Results (CBC)

Normal Ranges

Abnormal

If abnormal, please list results

Date Last Performed (Urinalysis)

Results (Urinalysis)

Normal Ranges

Abnormal

If abnormal, please list results

Date Last Performed (T4 or Thyroid Profile)

Results (T4 or Thyroid Profile)

Normal Ranges

Abnormal

If abnormal, please list results

If other diagnostics were performed, please describe

Copy of Medical Records(Required)

Will upload below (preferred)

Will email to [email protected]

Will fax to 706-608-8369

Upload - Copy of Medical Records(Required)

Max. file size: 50 MB.

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Behavioral Medicine
Canine Behavioral History Form
Patient Recheck Form
Feline Behavioral History Form
Behavioral Medicine Service Referring Veterinarian Form

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