Referral Form

Date: 06 Feb 2012 Time: 14:46:06

Service for Referral:

Surgery

Veterinary Rehabilitation

Cardiology

Ophthalmology

Emergency/Critical Care

Ultrasound

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.