Date: 08 Sep 2010 Time: 6:36:04
Service for Referral:
Surgery
Internal Medicine
Cardiology
Ophthalmology
Emergency/Critical Care
Exotics
Referring Veterinarian: Phone
Hospital Name:
Hospital Address:
Hospital Fax E-Mail Address:
Preference to receive patient updates:
E-Mail
Fax
Mail
Phone
Client's Name: Phone
Client's Address:
Patient's Name: Breed: Age: Sex: Weight:
Previous Medical Illnesses:
Presenting Problem:
History:
Condition of Patient:
Healthy Stable Critical Moribund
Items sent with Client:
X-Rays
Records
Lab Results
Medication
Pending Laboratory Tests (Please include dates submitted):
Blood
Idexx
Urine
Antech
Other:
Diagnostics Performed (Please include date and results):
Treatment/Medications (Please include doses/dosages):
Response to Treatment:
Additional Comments:
Please include radiographs, copies of laboratory tests, and a summary of the medical record. Radiographs will be returned promptly. Referral information may be mailed, sent with the client, or faxed. If using the mail, please allow enough time for the information to arrive in time for the consultation.