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 *

Is the client a staff member at your clinic? *

YesNo

Patient Information

Pet's Name *

Pet's Age or date of birth *

Pet's Weight (kg) *

Species *

Breed *

Sex *

Colour *

Does this patient require a muzzle or oral sedation for the consultation? *

YesNo

Referring Veterinarian Information

Doctor *

Clinic *

Phone *

Fax *

Address Line 1 *

Address Line 2

City/Town *

Province *

E-Mail *

are you the primary care Veterinarian? *

YesNo

Who is the Primary Care Veterinarian?

If Known

Dermatology History

What skin issues are you referring the patient for? *

(i.e., Itch, skin infections, ear infections, ear mass/polyp, pemphigus foliaceous etc.)
Please include a brief description.

Has the patient received the following medications? Please include the dose prescribed, for roughly how long and the response.

Have any diagnostics been performed (bloodwork, cytology, biopsies, imaging)?

Please upload any recent labwork from the last 6 months

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Other relevant medical history

Does the patient have any other medical issues?

heart murmur, IBD, liver disease, etc.

Are they on any other medications unrelated to their skin?

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

Patient Information

Referring Veterinarian Information

Dermatology History

Other relevant medical history

Important Information