REFERRAL FORM

 

Hospital/Clinic Name:        ____________________________________________

Phone Number:                    ____________________

Fax Number:                         ____________________       

Name of Referring Doctor:  ____________________

 

CLIENT INFORMATION:

Client Name: ___________________________________

Address:         ___________________________________

                        ___________________________________

Postal Code:   ____________

Phone (Hm)  _______________      (Wk)   _________________

 

Animal Name:_________________

Species:          _________________

Breed:             ________________________________

Sex: _______   Age/Birthdate: ____________    Color: __________  Wt: ___________

 

BRIEF HISTORY OF DERMATOLOGIC PROBLEM:

 

 

DIAGNOSTIC TESTS WHICH HAVE BEEN DONE: (for blood panel or biopsy reports, please send or fax a copy of the original; for TSH/T4 (first test most important), TRH, LDDS/HDDS, Cortisols etc. please fax the diagnostic report, plus any subsequent reports.

 

 

*Please have your client call us to set up an appointment*

 

 

 

TO PREPARE FOR THE INITIAL CONSULTATION, THE FOLLOWING INFORMATION IS IMPORTANT:

Þ     MEDICAL RECORDS - if history is too large to fit into the space provided on the referral form, please send or fax the medical records including biopsies, blood panels, thyroid tests etc.

Þ     BATHING - refrain from bathing the animal in any medicated shampoo for 3 to 7 days before the appointment.

Þ     FOOD - write down the brand name of food that is being fed as well as its first 5 ingredients - or - just cut out the ingredient label on the side of most bags of food. Also write down the names of any cookies, biscuits, treats or human food that is being fed regularly.

Þ     SHAMPOOS & MEDICATIONS - gather up any shampoos or medications that you have used within the last 4 to 6 months and bring them in with you.

 

TO PREPARE FOR SKIN TESTING, THE FOLLOWING RESTRICTIONS APPLY:

Þ     NO long acting Cortisone, Depomedrol or Allergy Desensitization injections 7 WEEKS before appointment.

Þ     NO Prednisone, Deltasone, Cortisone, Dexasone/Dexamethasone or Vanectyl-P tabs or injections, 3 WEEKS before appointment.

Þ     NO Antihistamines 2 WEEKS before appointment.

Þ     NO Glucocorticoid topicals (eye drops/ointments, ear drops/ointments, skin drops/ointments) 2 WEEKS before appointment.

Þ     In order to ease the itchiness that will likely prevail once stopping the above drugs, you can use an oatmeal based shampoo/rinse with cold water daily or you could use drugs such as Diazepam to relax the nerves.

Þ     It is not uncommon for us to do an initial consultation on an animal who is using any of the above drug therapies.  We are still able to begin our specific therapies and perform other valuable tests which will replace the need for the above medications. 

 

OTHER CONSULTATION INFORMATION:

Þ     The first consultation generally lasts about 1 hour.  There is no additional charge for consultations which exceed the hour. If intradermal skin testing is performed, the appointment will last anywhere between 1 1/2 to 2 hours.

Þ     We have a strict cancellation policy, which requires 24 hours notification, otherwise the client will be billed and/or be put on a prepayment probation in order to book the replacing appointment. We will do our best to confirm the appointment with the client, however it would help everyone concerned if you could point this out to your client if you are making the appointment for them.

Þ     Price breakdowns are as follows: ( medications, tests, treatments, professional services and GST are additional)

            At our Lower Mainland locations, the initial consultation is $139

            Intra Dermal Skin Testing is $309 (60 different allergens; mild sedative given; 25 minute in house test with results in 5 to 10 minutes)

            Allergy Desensitization Serum is $163 - $178 (10 - 12 ml serum vial, 1st one lasts 6 to 9 months, then the next vial lasts approx. 1 year).

Þ     Payment policies: Visa, Mastercard, Interac, Cash, NO CHEQUES, MEDICARD FINANCING AVAILABLE – must be approved before appointment. Please have the client contact us if they are interested.