Referring Vet Information

Please complete and email the form with all Labwork, Records, and Any Radiographs for every referral; also call to inform that a patient is being referred. Please leave a message if outside clinic hours for continued care on Thursday.

Name of Referring Veterinarian Clinic and doctor(s)?
Contact information for referring clinic:

Phone number: Email: Hours:

Client Name:Patient Name:

Species:Canine (Dog)Feline (Cat)

Other

Breed:

Color:

Sex: MaleFemale

Spayed (F) or castrated (M)?:YesNo

Date of birth/Age:

Up to date on vaccines?:YesNo

What type of Heartworm/Flea prevention is pet on?

Primary reason for visit and history – include TPR +/- BP initial and last recording with times?Major health history or medications routinely on? Diagnostics performed with results including any pending outside lab results:

IV cather (size, placement, time):

Medications received (mg, route, time):

Fluids administered (Type, rate, total volume):

Surgical procedures performed (type and time out of surgery):

Other important information:

Referring Vet Information

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