Practice Name

Practice Phone:

Client Name:

Client Email Address:
(if known)

Client Phone(s):

Pet Name:

                            Dog/Cat  M/F   MX / FX  Age:         Wt:

Primary Behavioral Concern:

Any Behavior Rx:
(Past and Present – Dose and Duration)

Any Current Medical Rx?
E.G. Phenobarb, Pred., Thyroxin, Other

Current Medical Conditions?
E.G. Arthritis, Allergy, Thyroid, Epilepsy,

Prefer an Email or Fax Report?

Give veterinary email or fax #

Please provide this information by leaving a phone voicemail message or by faxing this form plus any lab results and medical notes (within in the last six months) and any other comments pertinent to pet’s behavior.

The pet's attending DVM, retains the Veterinary-Client-Patient Relationship. Clients are called by an Veterinary Behavior Technician to explain and offer the Analysis offered by Dr. Tripp and Associates. The veterinarian and client receive a report on the Pet Behavior Analysis. The attending veterinarian retains overall responsibility for patient-related recommendations, and provides indicated diagnostic tests, prescriptions, and medical treatments.