Veterinary Psychiatric and Behavior Center in Fort Worth Texas

Veterinary Psychiatric and Behavior Center - Fort Worth, TX

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Veterinarian Referral Form

Use this form to refer a client to Dr. Tucker. We will send you a report when we see your client and their pet.

Referring Veterinarian Information

Referring Veterinarian Name*

Clinic Name*

Clinic Email*

Clinic Fax*

Phone*

Clinic Address*

Client Information

First Name*

Last Name*

Phone*

Alternate Phone

Email*

Address*

Patient Information

Species*

Canine

Feline

Avian

Other

Name*

Breed*

Color/Markings*

Age and Date of Birth*

Sex

Female

Female Spayed

Male

Male Neutered

Weight (in pounds)*

Medical History

Please send all medical files to info@veterinarypsychiatry.com

Include all laboratory testing.

When was the last full physical examination?*

Was the last physical examination*

Normal

Abnormal

Date of last Rabies Vaccination*

Month

Day

Year

Has any laboratory testing been done in the past 3 months?*

Yes

Does the patient have any current or past medical problems?*

Yes

Is the patient currently on any medications?*

Yes

How would you describe the pet’s behavior in your office? FAS = Fear, Anxiety, and/or Stress as per Fear Free℠* (Choose one option below)

Level 5 (High) - Severe signs of FAS with aggression such as growling, lunging, barking, hissing, snarling, and/or snapping. Intolerant of procedures.

Level 4 (High) - Severe signs of FAS without aggression, such as immobility, fidgeting, escape behavior, dilated pupils, excessive panting (dog), increased respiratory rate, trembling, tense closed mouth, ears back, tail tucked or thrashing (cat). May or may not be accepting any types of reinforcers. Not interested in interacting with team members and may be showing active avoidance (moving away).

Level 3 (Moderate) - Displays more than 2 moderate signs of FAS occurring more than 4 times in a minute. May refuse reinforcements for brief moments. Might take treats roughly at times. May also be hesitant to interact with team members but not actively avoiding team members.

Level 2 (Moderate) - Displays 1 to 2 moderate signs of FAS, such as ears slightly back or to the side, tail down, furrowed brow, slow movements or overly attention seeking, and/or panting with a tighter mouth (dog), occurring 4 or less times a minute. Readily accepts reinforcement (treats, toys, and attention). Still soliciting social interactions with team members.

Level 1 (Low) - Displays 1 or 2 mild signs of FAS, such as lip licking, avoids eye contact, turns head away without moving away, lifts paw, or partially dilated pupils, and/or panting but commissures of lips are relaxed, occurring less than 4 times a minute. Interested in reinforcers (treats, play, attention) and choses to interact with the team members.

Level 0 (Low) - No signs of FAS. Pet displays relaxed body language and solicits social interactions with team members.

Don't know, I was not present at the last examination or cannot remember.

Has this animal ever shown any aggression towards you or your staff members?*

Yes

Please indicate the behavior reasons for the referral. *

info@veterinarypsychiatry.com

818 W Terrell Avenue

Fort Worth Texas 76104

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Veterinary Psychiatric and Behavior Center provides specialized veterinary behavior consultations for dogs, cats, and other animals in Fort Worth, Texas, helping pets and their families address anxiety, aggression, and complex behavioral challenges.

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