West Brant Animal Hospital

693 Colborne Street West
Brantford, ON N3T 5L5

(519)756-9998

www.westbrantah.evetsites.net

Dr. Anthony Yu Veterinary Dermatology

West Brant Animal Hospital

693 Colborne St West, Brantford, ON N3T 5L5

t: 519-756-9998      f: 519-756-9901      westbrant@gmail.com

 

DERMATOLOGY REFERRAL QUESTIONNAIRE

(Printable Version at the Bottom)

(Please fill out and fax to clinic at number above)

 

DATE AND TIME OF APPOINTMENT:                                                    

CLIENT INFORMATION

 

OWNER'S SURNAME:                                                                FIRST NAME:      

 

ADDRESS:               

 

CITY/TOWN:              POSTAL CODE:      

 

HOME PHONE: (   )                      BUSINESS/CELL PHONE:  (   )                     E-MAIL:      

 

ALTERNATE CONTACT NAME:                                                       ALTERNATE CONTACT INFORMATION:  

 

PET?S NAME:          

 

PET?S WEIGHT:                        SEX: M   MN  F  FS             AGE:                      BREED:        

 

 

VETERINARY CLINIC INFORMATION

DOCTOR:          

 

CLINIC:           

 

ADDRESS:                             

 

CITY / TOWN:               POSTAL CODE:                

 

PHONE: (   )                    FAX: (   )           E-MAIL:      

                                        

PLEASE NOTE:

1. Do not bathe your pet for at least 5 days prior to your appointment and do not feed your pet for at least 12 hours prior to your appointment (UNLESS OTHERWISE SPECIFIED BY YOUR VETERINARIAN),

2. Please note that pets referred to our facility can only be treated for skin related disorders.  All other unrelated treatments or procedures will be conducted by your family veterinarian.

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 (AGE OF ONSET, SEASONALITY, OTHER) AND LESIONS NOTED:

     

 

 

 

 

 

 

THERAPEUTIC HISTORY:

PLEASE LIST MEDICATIONS USED, INCLUDING DOSE, DATES OF TREATMENT, DURATION OF THERAPY AND ANY RESPONSE:

DATE                                 MEDICATION                            DOSE/DURATION                      RESULT

     

                                                        

     

     

IS THE PET ON HEARTWORM OR FLEA PREVENTION?  NO   YES   IF YES, WHICH?       

 

 

DIAGNOSTIC TESTS:

PLEASE SEND ALONG COPIES OF ANY DIAGNOSTIC TESTS.  OTHERWISE, PLEASE LIST ANY DIAGNOSTIC TESTS PERFORMED, WITH DATE RUN AND FULL RESULTS:

     

 

File NameDescription / Comment
QuestionnairePlease click here for a printable version of the Dermatology Questionnaire