VBS RDVM Patient Referral Form

Patient Referral Form

Please use the following form for patient referral. It will be submitted to our office automatically after you select "Submit" at the bottom of the page. Our Client Care Representative will contact your client for scheduling.

Thank you for entrusting your patient to our care. Please don't hesitate to contact us with any questions at 877.203.5973 or info@vetbehaviorsolutions.com .

Date *

Month Day Year

Patient Name *

Species *

Canine Feline Other

Breed *

Sex *

Age *

Weight (lbs) *

Owner's Name *

First Name Last Name

Owner Phone Number *

Area Code Phone Number

Owner E-mail *

Reason for Referral (What is primary behavior problem?): *

Current treatment/medications for behavior problem: *

Other pertinent medical or behavioral history:

Please upload all pertinent medical records and lab results (previously run or currently pending)

If you do not have the ability to upload these records you can fax them to 877.240.4543 or email the file to info@vetbehaviorsolutions.com

Referring Veterinarian *

Referring Hospital *

Practice Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Practice Phone Number *

Area Code Phone Number

Practice Fax Number *

Area Code Phone Number

Referring Veterinarian Email *

Additional Comments or Requests: