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Dermatology Referral Questionnaire - Section B

Note: Fields with an asterisk (*) are required.
SECTION B TO BE COMPLETED BY THE REFERRING VETERINARIAN: Dear Doctor, Thank you for taking the time to complete the questionnaire. A written report will follow the examination. Please do not hesitate to call, should you have any questions about this, or any other case. Completed forms can be sent by faxed to 416-920-6185, or mailed to the DERMATOLOGY DEPARTMENT, VETERINARY EMERGENCY CLINIC, 920 YONGE STREET, SUITE 117, TORONTO, ONTARIO, M4W 3C7 STEVE WAISGLASS BSc, DVM, CertSAD, DACVD

CLIENT DATA
* DOCTOR:
CLINIC:
ADDRESS:
CITY/TOWN:
POSTAL CODE:
PHONE:
FAX:
* E-MAIL:
PET'S NAME:
OWNER'S NAME:
PET'S WEIGHT (KG):
SEX: Male Female
AGE:
BREED:

RELEVANT MEDICAL HISTORY
DOES THE PET HAVE ANY RELEVANT NON-DERMATOLOGICAL DISEASE? ARE THERE ANY ANTIBIOTIC OR ANESTHETIC SENSITIVITIES? IF SO, PLEASE DESCRIBE:
DERMATOLOGIC HISTORY:
PLEASE BRIEFLY DESCRIBE THE COURSE OF THE DISEASE AND LESIONS NOTED:
THERAPEUTIC HISTORY:
PLEASE LIST MEDICATIONS USED, INCLUDING DOSE, DATES OF TREATMENT, DURATION OF THERAPY AND ANY RESPONSE:
Is the pet on heartworm or flea prevention? Please list type:
DIAGNOSTIC TESTS:
PLEASE SEND ALONG COPIES OF ANY DIAGNOSTIC TESTS. OTHERWISE, PLEASE LIST ANY DIAGNOSTIC TESTS PERFORMED, WITH DATE RUN AND FULL RESULTS:
ANY SUGGESTIONS OR COMMENTS?

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