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    Canine Behavior Consultation Form

     

    Although this questionnaire is long, it is crucial for understanding your pet's problematic behavior and identifying other potential behavioral problems.

  • Owner Information

  • Wisconsin Veterinary Licensing Board requires that new veterinarian-client-patient relationships be established in person.  Thus I am unable to meet with new clients virtually or over the phone. 

    If you live beyond my travel radius you have a few options: 

    1. During the warm months only: we can meet at a sheltered area in a quiet park. I am not able to see out of town clients during the winter months.   Facilities willing to offer day rentals do not feel comfortable with the liability of a reactive dog in their facility.   Sorry! 

    2. I am happy to meet you at a friend or family's home who does live in the Dane County Area.  

    3. I can refer you to Force Free Trainers of Wisconsin where there is a list of other veterinarians that like me, see behavior only cases. 

     

  • Patient Information

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  • Acquisition Information

  • Household Information

  • Medical

  • Veterinarian Information

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  • Exercise

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  • Behavioral Concerns

  • Please fill out the section below regarding your top three concerns about your dog's behavior.  If you don't have three concerns you don't have to fill out all three.

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  • Previous Treatments and Recommendations

  • This section is designed to help evaluate any role previous treatment may have played in either your dog's problems or in their resolution. Please complete these tables to the best of your ability. If you feel that an explanation is warranted, then complete the "comment" section at the bottom.

  • Training

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  • Previous Recommendations

    It's helpful to know what treatments, tricks, or strategies clients have tried or have had recommended to them to alter their dog's behaviors. Tick the items below if they were suggested and/or attempted.

    It is okay if you chose not to try something that was suggested or vice versa you tried something that wasn't suggested.  Recommendations and attempted solutions are all helpful to know.

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  • Behavior Screen for: Separation Anxiety, Noise Phobia, and Compulsive Repetitive Behaviors

  • Seperation Anxiety

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  • Noise Phobias

  • Compulsive or Rituatlistic Behavior Screen

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  • Aggression Screen

  • Human Bite Incidences

  • Dog Bite Incidences

  • Authorization of Treat Patients Showing Aggression

  • AUTHORIZATION TO TREAT AGGRESSION

    I certify that I am the owner of the animal named below and that I have sought behavioral counseling for my pet and advice on decreasing its aggressiveness.

    If your dog or cat is showing aggressive behaviors, you should be aware of the following:

    • Any animal who is aggressive for any reason can do serious damage and harm. It is important to understand that aggression by animals can cause injury, including fatal injury, to other animals, to other people and to you.
    • Treatment for aggressive behavior is an inexact science, and it is impossible to insure or guarantee that any pet including yours will not cause harm in the future.
    • I understand that it is my responsibility to take appropriate precautions to prevent my pet from causing harm to others.These precautions may include, but are not limited to, informing people of your pet’s tendency for aggressive behavior, keeping you pet on a leash, muzzled or with a head collar, and/or keeping your pet restrained behind doors, gates, or fencing.
    • Owning a cat or dog carries with it responsibilities, including responsibility and potential liability for any damage the dog or cat does to people or property. This responsibility is not changed or transferred by seeking behavioral help.
    • It is you responsibility to be aware of and to comply with all state and local ordinances concerning aggressive animals. If your pet is exhibiting aggression and it causes harm in the future, you may be held liable for such harm. Proof of current Rabies vaccination should accompany your completed history forms or be found in your medical records.

    I understand that treatment for aggressive behavior may include medication, behavior modification, and environmental management. These may be effective for decreasing aggressive behavior but cannot guarantee that the aggression will be completely controlled or prevented. Problems involving pathological behaviors, including aggression, are never cured but they can often be treated and managed, to the point where the dog or cat can live a happy life. Failure to manage and treat behavioral and pathological problems may lead to euthanasia in some cases. I also understand that the only way to ensure absolutely that my pet will never cause harm in the future is to euthanize him/her (end its life). Even as a last resort, the death of a pet is an outcome that everyone would seek to avoid, if at all possible.

    I hereby certify that I have read and understand the above and that I am signing this authorization with the full understanding that the treatment given my pet may not eliminate its aggressive behavior. I also certify that I will not hold Dr. Lewis or Lewis Veterinary Behavior Solutions responsible for any acts of aggression that my pet may perform in the future.

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  • Permission To Treat

  • CLIENT ACKNOWLEDGEMENTS

    Behavior problems are treated with a combination of the following:

    • Behavior modification exercises
    • Environmental management
    • Training tools, and/or supplements
    • Pharmacological agents (medication alone will not resolve your pet’s problem)

    Your initial consultation includes:

    • Behavior evaluation (up to 2 hours)
    • Assessment/diagnosis
    • Written treatment plan
    • Demonstration of behavior modification techniques (to the extent possible)
    • Three months of complimentary email follow-up support

    The cost of the initial evaluation is based on the time required to analyze your pet’s behavior problem, describe the treatment plan, and generate written instructions. Fees cover the time invested by the doctor and are therefore not refundable after completion of the initial consultation, regardless of case outcome.  Payment in full is required at the initial consultation.
    Treatment for behavioral conditions is a long-term process. While you may see some immediate improvements after initiating treatment, many problem behaviors take several months to improve. Every animal is an individual and can respond differently to behavioral management and medications. Some behavioral treatment plans will require adjustments depending on your pet’s response to treatment. While I have a high level of success in treating behavior cases, I am  unable to guarantee resolution of every problem. Successful outcomes rely heavily on your commitment and ability to comply with the suggested treatment plan.  

    By completing these forms and signing this consent form, you give permission for us to evaluate, assess, formulate a treatment plan, and treat your dog or cat.  

    INFORMED CONSENT FOR THE USE OF MEDICATION
    Dr. Lewis may discuss and/or recommend the use of medication(s) as part of your pet’s comprehensive treatment plan. Many of the medications that are prescribed for the treatment of behavioral problems are not expressly approved by the FDA (Food and Drug Administration) for all or any animal species and their use is considered “extra-label.” This means that safety, effectiveness, and side-effects have not been comprehensively established for the purpose or species used. Side effects and adverse effects may include but are not limited to lethargy, digestive upset, and behavioral changes. Extra-label drug use is a legal and well-accepted practice for veterinarians to prescribe medications. 


    I, the undersigned, being the owner or duly authorized agent for the owner of the animal named below, understand that a prescribed drug may not be approved for use in dogs and/or cats for the condition being treated. I understand that the drug is being prescribed in the hopes that it will be beneficial for my pet. I understand it is possible that this drug may not alter the course of the behavior problem, and that my animal may continue with the behavior problem whether or not the medication is administered.


    I understand that I should monitor my pet for adverse effects and that if any were to occur, I should contact Dr. Lewis or my referring veterinarian as soon as possible. I also understand that if there is an undesirable change in my pet’s behavior or the problem gets worse, the drug should be discontinued and I should contact Dr. Lewis or my referring veterinarian. No other drugs, herbal remedies, or supplements will be used at the same time as this medication except as discussed with Dr. Lewis.

     
    I hereby give my informed consent to the administration of this drug to my animal. I accept full responsibility for all actions that may occur from the use of this drug.

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