Request for a Pet Behavior History Analysis
Submitted by DVM to Dr. Rolan Tripp

Animal Behavior Network (ABN) 1-800-372-3706 Fax/Phone
(or) Request Dr. Tripp at 1-800-745-4725 Antech Doctor Consult Line

Please print clearly

Date:
Attending Veterinarian Name:
Hospital Name and City:
Hospital Phone:
Client Name:
Client Email Address: (if known)
Client Phone(s):
Pet Name, Species and Breed:
Primary Behavioral Concern:
Prefer an Email or Fax Report?

By submitting this form, I confirm that I retain the Veterinary-Client-Patient-Relationship for this pet and client and that I am requesting ABN to contact my client and offer this service (at no obligation). If my client chooses an Analysis, I understand that all behavior-related reports and recommendations for medical tests, prescriptions, and medical treatments will be sent to me by email or fax to add to my clients medical record, and that I may consult (at no charge) at any time with the ABN Veterinary Behavior Consultant and Veterinary Behavior Technician regarding recommendations for this case.

Additional Comments: