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Dermatology Referral Form

Please advise your clients that Canada West Veterinary Specialists will contact them directly to set up the appointment. Your clients are invited to complete a thorough history questionnaire in advance of their arrival at Canada West Veterinary Specialists and bring this form to the appointment.

Pet owners can download the Dermatology New Patient Owner Questionnaire on our website.

If the pet is referred for intradermal allergy testing, please note that certain medications need to be discontinued prior to the appointment. Please refer to the Intradermal Allergy Testing Protocol (available on our website).

If drug withdrawal is not possible, a dermatology consultation is still a valuable option.




Referring Veterinarian Information

Client and Patient Information





































Case History Summary (Mandatory)

Please provide a brief synopsis of the patient’s dermatologic condition including symptoms, duration, degree of pruritus, treatments/medications and their effect on the condition.

Previous Diagnostic Test(s)

Please check and attach results of any laboratory tests.






























Additional History

Pet’s temperament, owner compliance, known adverse/allergic reactions to medications (i.e. antibiotics, anesthesia, sedation, vaccinations, shampoos, ear cleaners, ear drops etc.), health problems, special requests, your expectations as the referring veterinarian, etc.

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