Referral Columbia – SouthEast Veterinary Dermatology

Referring Clinic *

Referring Veterinarian *

Referring Veterinary Clinic Email *

Please list all veterinary clinics/specialty hospitals that your client has seen in the last five years

Referral Type

Standard referral (no phone consult needed)

Standard phone consult (no referral at this time)

Phone consult and referral

Clinic Phone

Clinic Fax

Client Name *

Client Phone *

Patient Name *

Patient Breed *

Color

Sex *

Spayed/Neutered

Yes

No

Animal

Patient Age *

Please specify what diets your clinic carries

Please specify what unflavored heartworm and flea preventions your clinic carries

Chief complaint (check all that apply) *

Other

Has this pet been seen by another dermatologist or had allergy testing done elsewhere? Please specify, if applicable. *

Are you referring this patient for allergy testing?

When is the last time this patient received corticosteroids or antihistamines? What kind? At what dose were these given?

Has the patient needed sedation to be examined? *

Yes

No

Please send all medical records via email to infocolumbia@adcmg.com, or fax them to (803) 999-1839.