Behavioral Referral Form Behavioral Referral Form Referring Veterinarian * Clinic * City * State * Phone * Email * Preferred Method of Contact * EmailPhone Preferred Time of Contact * Owner's Name * Spouse or Co-owner * Address * City * State * Zip * Phone * Cell * Email * Pet's name * Species * Sex * Spayed/Neutered * Age * Breed * Weight * DHLPP * CurrentDue Rabies * CurrentDue Fecal test within the past 6 months? * Date of last deworming? * Heartworm or FELV/FIV test within the past year? * Result * On Heartworm prevention? * Name * Last veterinary exam * How does the pet behave at clinic and for care? (panting, growling, staring, pacing, shaking, hiding, calm, relaxed?) * Medications pet is on presently, including start date and any behavior meds * Current medical conditions including chronic – ( skin, ear, eye, arthritis, past trauma or surgery) * Are these being treated or managed? * What meds? * Behaviors you see as a problem that need to be addressed: ( can add more info as needed) * Severity of behavior problem in your professional opinion – safety of family/ welfare of animal * Did you refer and if so when? * If client self referred, did the client ever bring up behavior problem to you or your staff ( this is to help me help DVM/Vet Staff with client education) * Best way for Dr Foote to send report after consultation * Snail MailEmail If email, what is the best email for referring DVM to receive it?