REFERRING VETERINARIAN
PRACTICE NAME AND ADDRESS
PRACTICE TELEPHONE
PRACTICE EMAIL
OWNER’S NAME
PATIENT’S NAME/ AGE/ SPECIES AND BREED
GENDER/ NEUTERED STATUS AND DATE OF NEUTERING
PASSPORT/MICROCHIP NO. (IF RELEVANT)
DATE OF LAST HEALTH CHECK
PRESENTING PROBLEM
I HEREBY ACKNOWLEDGE MY APPROVAL FOR THE CLIENT DESCRIBED ABOVE TO BE REFERRED FOR MANAGEMENT, TRAINING AND/OR BEHAVIOURAL THERAPY REGARDING THE CURRENT PROBLEM TO:
Member number ;- 25007P Leona Gerwat-Clark Clinical Animal Behaviourist Leonaclark@rocketmail.com 07739846628 (WhatsApp)
Postal address: 4th Floor Silverstream House 45 Fitzroy Street Fitzrovia London W1T 6EB
In person areas covered South East London & Somerset.
Remote services all areas national & international
THE ABOVE MAY NEED TO DISCUSS SIGNS OF SPECIFIC MEDICAL CONDITIONS WITH YOU, THE REFERRING VETERINARIAN, DURING THE COURSE OF THEIR WORK. THIS IS AT NO TIME TO BE TAKEN AS AN ATTEMPT TO DIAGNOSE ANY MEDICAL CONDITION UNLESS THE MEMBER IS THEMSELVES A QUALIFIED VETERINARIAN WHO EXPLICITLY STATES A DIAGNOSIS.
SIGNED
DATE
I, , THE OWNER/PERSON WITH FULL LEGAL RESPONSIBILITY* OF THE ABOVE NAMED ANIMAL, CONSENT TO THE DISCLOSURE OF CLINICAL INFORMATION REGARDING THIS ANIMAL BY MY VETERINARY SURGEON FOR THE PURPOSES OF BEHAVIOUR THERAPY. I HEREBY AUTHORISE MY VETERINARIAN AND BEHAVIOURIST TO DISCLOSE DETAILS ABOUT AND DISCUSS THIS CASE. * PLEASE STATE CAPACITY .
