Referring Clinic / Doctor

Clinic Name

Doctor Name

Email Address

Phone Number for Consultation

Consultation Details

Pet Owner Information

First Name

Last Name

Phone

Email Address

Address

City

State

Zip Code

Patient Information

Pet Name

Age / Date of Birth

Species

Breed

Sex

Weight (lb/kg)

Emergency Information

Presenting Complaint

Diagnosis / Differentials

Current Medications, Laboratory Findings, Recent Surgery, Other. Please include the time medicine was last given or when treatments were complete. Send radiographs and copy of blood work with owner.

Instructions for Emergency Doctor. Please include medication doses, route of administration, fluid type and rate.

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Bill us for client charges

Patient is to return to my hospital for continued care

Please keep patient for workup

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Referring Clinic / Doctor

Pet Owner Information

Patient Information

Emergency Information

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