Yu of Guelph Veterinary Dermatology
519-821-SKIN (7546)

Dermatology Referral Questionnaire

From this point forward hand written or faxed referrals will no longer be accepted. Appointments will not be confirmed until the referral form (see below) has been received.

All referrals need to be done on-line, through our website. The reason for this request is that we wish to eliminate incorrect interpretation of handwriting and illegible faxed documents in order that we may provide the best care possible for your patients, along with timely and accurate communications with your office and your clients. We look forward to supporting your clinics with their veterinary dermatologic needs.

Thank you in advance for your co-operation.
Dr. Yu and THE Derm Team.


Client Information

**Please book appointment for your client directly with the clinic at all locations except Guelph**



















 Kg






Veterinary Clinic Information










Please Note:

  1. Do not bathe your pet for at least 5 days prior to your appointment and do not feed you pet for at least 12 hours to your appointment (UNLESS OTHERWISE SPECIFIED BY YOUR VETERINARIAN),
  2. Please note that pets referred to our facility can only be treated for skin related disorders. All other unrelated treatment or procedures willl be conducted by your family veterinarian.

Relevant Medical History



Dermatologic History



Therapeutic History

Please list medications used, including does, dates of treatment, duration of therapy and any response:

Date Medication Dose/Duration Result




Diagnostic Tests


Attached Files: