Veterinary Referral Form

In line with the APBC code of conduct, all behavioural cases must be seen on veterinary referral.

Please complete the referral form below and upload a copy of the patient's clinical history, including any relevant test results.

Alternatively you can downloaded the referral form here and email it, along with the clinical history to; karen@petbehaviourconsulting.co.uk

Following each consultation I'll send a summary report to the referring Veterinary Surgeon so your records are kept up to date.

Practice Details

Veterinary Practice name

Address, including postcode

Contact number

Client's name

Client's address

Contact number

Dog's name

Dog's breed, mix or cross

Male/Female

Is the patient neutered or entire?

Brief desciption of behaviour problem

Can you clinically examine the patient?

Did the patient require additional forms of restraint (e.g. owner or nurse holding, use of a muzzle, etc.)?

If referring directly, how would the owner prefer to be contacted? Required

Phone

Self referral - I have been requested to complete the referral

I acknowledge my consent for the above client and patient to be referred to Karen Bachell with regard to training/behavioural issues

Your Signature

Print name

Date signed

Upload History

Upload supported file (Max 15MB)

Upload Additional File

Upload supported file (Max 15MB)

Upload Additional File

Upload supported file (Max 15MB)

Upload Additional File

Upload supported file (Max 15MB)